Predictors of treatment outcomes in ANCA-associated vasculitis with severe kidney failure

Taewoo Lee, Adil Gasim, Vimal K. Derebail, Yunro Chung, Julieanne G. McGregor, Sophia Lionaki, Carolinej Poulton, Susan L. Hogan, J. Charles Jennette, Ronald J. Falk, Patrick H. Nachman

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Abstract

Background and objectives: In ANCA-associated GN, severe renal dysfunction portends a poor prognosis for renal recovery and patient survival. This study evaluated the prognostic factors affecting renal and patient outcomes in patients presenting with severe kidney failure to guide immunosuppressive therapy. Design, setting, participants, & measurements: This study retrospectively evaluated clinical and histopathologic characteristics of 155 patients who underwent biopsy between October 1985 and February 2011 (median eGFR at presentation, 7.1 ml/min per 1.73 m2; 87% required hemodialysis), all treated with immunosuppressive medications. Three outcomes of interest were measured: patient survival, renal survival, and treatment response (defined as dialysis-free survival without active vasculitis by 4 months after biopsy). Competing risk, Cox, and logistic regression analyses were conducted for each outcome measure. Results: Within 4 months after biopsy, treatment response was attained in 51% of patients, 35% remained on dialysis, and 14% died. In a competing risk analysis, estimated cumulative incidence rates of ESRD and disease-related mortality were 26% and 17% at 1 year and 32% and 28% at 5 years, respectively. Cyclophosphamide therapy and treatment response by 4 months were independently associated with patient and renal survival, adjusting for the percentage of normal glomeruli, histopathologic chronicity index score, and baseline clinical characteristics. Only 5% of patients still dialysis dependent at 4 months subsequently recovered renal function. Low chronicity index score (odds ratio [OR], 1.16; 95% confidence interval [95% CI], 1.04 to 1.30, per unit decrease) and baseline eGFR>10 ml/min per 1.73 m2 (OR, 2.77; 95% CI, 1.09 to 7.01) were significantly associated with treatment response by 4 months. Among cyclophosphamide-treated patients, the likelihood of treatment response was >14% even with highest chronicity index score and eGFR<10 ml/min per 1.73 m2. Conclusions: Although low baseline renal function and severe renal scarring are associated with lower treatment response rate, no “futility” threshold could be identified. Conversely, continued immunosuppressive therapy beyond 4 months is unlikely to benefit patients who remain dialysis dependent.

Original languageEnglish (US)
Pages (from-to)905-913
Number of pages9
JournalClinical Journal of the American Society of Nephrology
Volume9
Issue number5
DOIs
StatePublished - Jan 1 2014
Externally publishedYes

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Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis
Renal Insufficiency
Kidney
Dialysis
Immunosuppressive Agents
Therapeutics
Biopsy
Cyclophosphamide
Survival
Odds Ratio
Confidence Intervals
Medical Futility
Antineutrophil Cytoplasmic Antibodies
Vasculitis
Chronic Kidney Failure
Cicatrix
Renal Dialysis
Logistic Models

ASJC Scopus subject areas

  • Epidemiology
  • Critical Care and Intensive Care Medicine
  • Nephrology
  • Transplantation

Cite this

Predictors of treatment outcomes in ANCA-associated vasculitis with severe kidney failure. / Lee, Taewoo; Gasim, Adil; Derebail, Vimal K.; Chung, Yunro; McGregor, Julieanne G.; Lionaki, Sophia; Poulton, Carolinej; Hogan, Susan L.; Jennette, J. Charles; Falk, Ronald J.; Nachman, Patrick H.

In: Clinical Journal of the American Society of Nephrology, Vol. 9, No. 5, 01.01.2014, p. 905-913.

Research output: Contribution to journalArticle

Lee, T, Gasim, A, Derebail, VK, Chung, Y, McGregor, JG, Lionaki, S, Poulton, C, Hogan, SL, Jennette, JC, Falk, RJ & Nachman, PH 2014, 'Predictors of treatment outcomes in ANCA-associated vasculitis with severe kidney failure', Clinical Journal of the American Society of Nephrology, vol. 9, no. 5, pp. 905-913. https://doi.org/10.2215/CJN.08290813
Lee, Taewoo ; Gasim, Adil ; Derebail, Vimal K. ; Chung, Yunro ; McGregor, Julieanne G. ; Lionaki, Sophia ; Poulton, Carolinej ; Hogan, Susan L. ; Jennette, J. Charles ; Falk, Ronald J. ; Nachman, Patrick H. / Predictors of treatment outcomes in ANCA-associated vasculitis with severe kidney failure. In: Clinical Journal of the American Society of Nephrology. 2014 ; Vol. 9, No. 5. pp. 905-913.
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AU - Lionaki, Sophia

AU - Poulton, Carolinej

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AU - Falk, Ronald J.

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