University of Groningen. Anca associated vasculitis Boomsma, Maarten Michiel

Transcription

1 University of Groningen Anca associated vasculitis Boomsma, Maarten Michiel IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2001 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): Boomsma, M. M. (2001). Anca associated vasculitis: occurrence, prediction, prevention, and outcome of relapses Groningen: s.n. Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date:

2 ANCA ASSOCIATED VASCULITIS: OCCURRENCE, PREDICTION, PREVENTION, AND OUTCOME OF RELAPSES Maarten Boomsma

3 The studies described in this thesis were financially supported by a grant from the University Hospital Groningen (AZG-stimuleringsgelden) Publication of this thesis was financially supported by: De nierstichting Nederland De Friedrich Wegener stichting Stichting Ontwikkeling Klinische Immunologie Groningen Groningen University Institute for Drug Exploration GUIDE Nationaal Reumafonds Baxter BV Boehringer Ingelheim BV BYK BV Central laboratory of the Netherlands Blood Transfusion Service (CLB) Janssen-Cilag BV Euro-diagnostica BV Leo Pharma Novartis Pharma BV Roche Pharmaceuticals BV Servier BV Wyeth BV Cover illustrations: Disease-free survival curve Cover design: Nicoline Boomsma Monique van Olphen Maarten Boomsma ANCA associated vasculitis: occurrence, prediction, prevention, and outcome of relapses Maarten Boomsma Thesis University Groningen ISBN M.M. Boomsma, Groningen, 2001 All rights reserved Printed by van Denderen BV Groningen

4 RIJKSUNIVERSITEIT GRONINGEN ANCA ASSOCIATED VASCULITIS: OCCURRENCE, PREDICTION, PREVENTION, AND OUTCOME OF RELAPSES Proefschrift ter verkrijging van het doctoraat in de Medische Wetenschappen aan de Rijksuniversiteit Groningen op gezag van de Rector Magnificus, dr. D.F.J. Bosscher, in het openbaar te verdedigen op woensdag 12 september 2001 om uur door Maarten Michiel Boomsma geboren op 3 december 1972 te Leiden

5 Promotores : Prof.dr. C.M.G. Kallenberg Prof.dr. J.W. Cohen Tervaert Referent : dr. C.A. Stegeman Beoordelingscommissie : Prof.dr. P.E. de Jong Prof.dr. M.H. van Rijswijk Prof.dr. S.J. van der Linden (Academisch Ziekenhuis Maastricht) ISBN-nummer :

6 Paranimfen : Marcel van der Leij Geert Kamps

7 Contents Chapter 1: General Introduction 1 Chapter 2: Prevention of relapsing disease in necrotizing small-vessel vasculitis, antibody directed and anti-bacterial directed treatment Disease-modifying therapy in vasculitis. Birkhäuser Verlag, Basel: in press 9 Chapter 3: Levels of soluble erythrocyte protein C receptor in patients with Wegener s granulomatosis Submitted for publication 27 Chapter 4: Image analysis; a novel approach for the quantification of antineutrophil cytoplasmic antibody levels in patients with Wegener s Granulomatosis In preparation 43 Chapter 5: Native and recombinant proteins to analyze auto-antibodies to myeloperoxidase in pauci-immune crescentic glomerulonephritis Journal of Immunological Methods 2001;254: Chapter 6: Prediction of relapses in Wegener s granulomatosis by measurement of Anti Neutrophil Cytoplasmic Antibody levels; a prospective study Arthritis and Rheumatism 2000;43: Chapter 7: Prevention of relapses of vasculitis in antineutrophil cytoplasmic antibody associated vasculitis by treatment based on autoantibody levels as detected by solid phase assay In preparation 91

8 Chapter 8: Trimethoprim-sulfamethoxazole monotherapy for active limited Wegener's granulomatosis Submitted for publication 107 Chapter 9: Prevalence of reduced bone mineral density (BMD) in patients with Anti-Neutrophil Cytoplasmic antibody associated Vasculitis and the role of immunesuppressive therapy; a cross-sectional study Submitted for publication 117 Chapter 10: Comparison of Dutch and US patients perceptions of the effects of Wegener s granulomatosis on health, function, income, and interpersonal relationships: comment on the article by Hoffman et al Arthritis and Rheumatism 1999;42: (letter) 131 Patients' perceptions of the effects of systemic lupus erythematosus on health, function, income, and interpersonal relationships; a comparison with Wegener's granulomatosis Submitted for publication 135 Chapter 11: Summary and general discussion 147 Nederlandse samenvatting 157 Dankwoord 165

9 Introduction Chapter 1

10 Chapter 1 Vasculitis Vasculitis is characterized by inflammation of vessel walls. Vessels of any type in any organ can be affected resulting in a wide variety of signs and symptoms. The disease may be systemic or limited to one or just a few organs systems. Vasculitis may be present as a primary disease of the blood vessels (primary or idiopathic vasculitis, see Table 1 (Jennette et al., 1994)) or as part of another underlying disease (secondary vasculitis, e.g. vasculitis associated with serum sickness, viral hepatitis, systemic lupus erythematosus, rheumatoid arthritis). These secondary vasculitides are, in contrast to primary vasculitis, frequently characterized by immune complex deposition within the vessel wall suggesting that immune complex deposition from the circulation or in situ complex formation is pathophysiologically related to the vasculitic process. Table 1 Classification of systemic primary / idiopathic vasculitides I. Predominantly affecting large- and medium-sized blood vessels 1. Takayasu's arteritis 2. Giant cell arteritis / temporal arteritis II. Predominantly affecting medium-sized blood vessels 1. Polyarteritis nodosa 2. Kawasaki's disease III. Predominantly affecting medium- and small-sized blood vessels 1. Churg-Strauss syndrome 2.Wegener's granulomatosis 3.Microscopic polyangiitis IV. Predominantly affecting small-sized blood vessels 1.Henoch-Schönlein purpura 2.Essential cryoglobulinemic vasculitis 3.Cutaneous leukocytoclastic angiitis (adapted from Jennette et al.,1994) Antineutrophil cytoplasmic antibodies (ANCA) Autoantibodies directed against constituents of polymorphonuclear leukocytes and/or monocytes were first described in 1982 by Davies et al. in a few patients with renal vasculitis (Davies et al. 1982). In 1985 it became apparent that ANCA are a sensitive and specific marker for Wegener's granulomatosis (van der Woude et al., 1985). Since then, ANCA have also been described in patients with other forms of vasculitis, i.e. microscopic polyangiitis (Savage et al., 1987), Churg-Strauss syndrome (Cohen Tervaert et al., 1991a), and renal limited vasculitis (= idiopathic necrotizing crescentic glomerulonephritis) (Falk et al., 1988). ANCA were originally detected by indirect immunofluorescence on ethanol fixed neutrophils (Wiik et al., 1989). At least three different patterns of fluorescence have been distinguished: a 2

11 Introduction cytoplasmic/classic pattern (canca) with accentuation of the fluorescence intensity in the area with the nuclear lobes, a perinuclear pattern (panca), and a more diffuse cytoplasmic staining pattern (atypical ANCA). Approximately 90% of the sera that produce a canca pattern react with proteinase 3 (PR3), a serine protease from the azurophilic granules of myeloid cells (Falk et al., 1997). In patients with primary systemic vasculitis predominantly affecting medium- and small-sized blood vessels, approximately 75% of the sera producing a perinuclear pattern (panca) react with myeloperoxidase (MPO), a myeloid lysosomal enzyme (Cohen Tervaert et al., 1991b). In ANCA-positive patients with other nonvasculitic diseases (e.g. inflammatory bowel disease) often antigenic specificities are recognized, such as lactoferrin and elastase, may occur (Kallenberg et al., 1992). The diagnostic potential of PR3-ANCA and MPO-ANCA are now fairly well established (Table 2). In a patient with signs and symptoms of vasculitis, ANCA with specificity for PR3 (PR3-ANCA) suggests a diagnosis of Wegener's granulomatosis, whereas ANCA with specificity for MPO (MPO- ANCA) is highly sensitive for either microscopic polyangiitis, idiopathic necrotizing crescentic glomerulonephritis, or active Churg-Strauss syndrome (Cohen Tervaert et al., 1996). A number of in vitro and animal studies, in addition, have suggested that ANCA are involved in the pathophysiology of ANCA related syndromes. Table 2 Characteristics of ANCA-associated vasculitides Disease Clinical Anti-PR3 Antibody Anti-MPO Antibody Churg-Strauss syndrome Asthma, eosinophilia, neuropathy Wegener's granulomatosis Nose bleeds, nephritis, lung infiltrates Microscopic polyangiitis Nephritis, purpura, hemoptysis Idiopathic necrotizing and / or crescentic glomerulonephritis Nephritis, malaise PR3= proteinase 3;MPO= myeloperoxidase; ++++ = > 70%of patients; +++ = 30-70% of patients; ++ = 10-30% of patients; + = 3-10% of patients (adapted from Cohen Tervaert et al., 1996) ANCA-associated vasculitis Within the spectrum of primary vasculitic syndromes, the ANCA related syndromes form a distinct group with overlapping features. Most patients have a prodromal flu-like onset consisting of malaise, myalgias, arthralgias, fever and weight loss. This flu-like onset appears within days to weeks before the onset of overt vasculitic or nephritic disease. ANCA associated vasculitis includes four major syndromes: Wegener's granulomatosis, Churg- Strauss syndrome, microscopic polyangiitis, and idiopathic necrotizing and/or crescentic glomerulonephritis (Table 2). Wegener's granulomatosis is differentiated from the others by the presence of necrotizing granulomatous inflammation of the upper and lower respiratory tract, which is usually accompanied by systemic necrotizing small vessel vasculitis and 3

12 Chapter 1 glomerulonephritis. Churg-Strauss syndrome is differentiated by the presence of (a history of) asthma, allergic rhinitis, systemic eosinophilia, in addition to systemic vasculitis with or without glomerulonephritis. Microscopic polyangiitis is characterized by necrotizing and/or crescentic glomerulonephritis and a multisystem vasculitis involving small vessels. Microscopic polyangiitis shares many features with Wegener's granulomatosis and Churg- Strauss syndrome, but lacks necrotizing granulomatous inflammation of the respiratory tract and asthma (Jennette et al., 1994). In idiopathic necrotizing and/or crescentic glomerulonephritis the vasculitic process is limited to the kidneys. The diseases mentioned above affect people of all ages but are most common in older adults in their 50s and 60s, and they affect men and women equally (Pettersson et al., 1995; Falk et al., 1990). ANCA related small-vessel vasculitides are potentially life-threatening diseases with high mortality. Prolonged immunosuppressive therapy (>1 year) with cyclophosphamide and steroids is effective in inducing disease remission and preventing early relapses in most vasculitic disorders (Balow et al., 1993; Gaskin et al., 1992; Fauci et al., 1978; Fauci et al., 1983; Hoffman et al., Ann Int Med 1992; Andrassy et al., Clin Nephrol 1991). Continuous use of cyclophosphamide to sustain remission can not be recommended, however, since this treatment regimen is associated with severe and potentially lethal adverse effects such as the occurrence of opportunistic infections and the development of malignancies (Stillwell et al., 1988; Radis et al., 1995). Therefore, cyclophosphamide is tapered or stopped and replaced by azathioprine once remission is achieved to prevent adverse effects, a policy recently tested in a rigorous multicenter trial and proven to be equally effective in the follow-up for 18 months (Gaskin et al., 1992; Jayne, 2000). Azathioprine is considered less effective in inducing remission than cyclophosphamide, but its long-term toxicity is much lower (Bouroncle et al., 1967; Norton et al.,1968). Other alternative maintenance therapy regimens, such as methotrexate (de Groot et al., 1996), cyclosporin A (Haubitz et al., 1998), mycophenolate (Nowack et al., 1999), or trimethoprim-sulfamethoxazole (Stegeman et al., 1996) have been described. Relapses, however, are frequently observed in these forms of vasculitis and treatment in such cases has to be intensified or reinstituted (Hoffman et al., 1992; Gordon et al., 1993; Nachman et al., 1996; Guillevin et al., 1999; Reinhold-Keller et al., 2000). Interestingly, changes in ANCA during followup generally reflect disease activity. It has been demonstrated that the persistence or reappearance of ANCA is a risk factor for the development of a relapse of disease activity (Stegeman et al., 1994; De'Oliviera et al., 1995; Jayne et al., 1995). In addition, relapses of Wegener's granulomatosis are frequently preceded by rises in the titer of cytoplasmic/classic ANCA (canca) as detected by indirect immunofluorescence (Cohen Tervaert et al., 1989) and relapses can be prevented by treatment with immunosuppressives based on rises in canca (Cohen Tervaert et al., 1990). These data suggest a pathophysiological role in vivo for these autoantibodies. 4

13 Introduction Aim of this thesis During follow-up, relapses of disease activity occur in the majority of patients with ANCA associated vasculitis. The general objective brought together in this thesis was to further elucidate the characteristics and consequences of these relapses. Investigated items are the occurrence, the prediction, the prevention, and the morbidity of clinical relapses in ANCA associated vasculitis. First, we reviewed the literature on the occurrence of relapses and possibilities to prevent relapses (Chapter 2). Secondly, as the relation between changes in ANCA and disease activity are variable, we investigated whether markers of endothelial damage, inflammation, and/or autoantibodies to endothelial cells could be better predictors of disease activity in Wegener's granulomatosis than ANCA (Chapter 3). To elucidate the value of quantitative image analysis for monitoring ANCA levels, we compared this technique with the currently available semi quantitative (i.e. indirect immunofluorescence) and quantitative (i.e. ELISA) techniques using samples from a cohort of PR3-ANCA positive patients with Wegener's granulomatosis. The results are described in Chapter 4. Next, we investigated the prevalence of MPO-ANCA in a large cohort of patients with biopsy-proven pauci-immune (= few or no immune deposits) crescentic glomerulonephritis using different assays and (recombinant) antigens for the detection of MPO-ANCA (Chapter 5). The results of a prospective study in 100 patients with Wegener's granulomatosis designed to assess the value of serial quantification of ANCA by indirect immunofluorescence and antigen-specific enzyme-linked immunosorbent assay (ELISA) for the prediction of relapses are presented in Chapter 6. Since PR3-ANCA detection by ELISA proved superior to indirect immunofluorescence, a randomized multi-center study was conducted in PR3-ANCA positive patients with vasculitis to investigate the value of early treatment based on serial quantification of ANCA by ELISA for the prevention of relapses (Chapter 7). In Chapter 8, ANCA levels were measured in a cohort study of consecutive patients with Wegener's granulomatosis presenting with disease activity limited to the upper and lower airways who were treated with trimethoprimsulfamethoxazole only. We evaluated whether ANCA levels in these patients were helpful to predict treatment failure. It is generally accepted that relapses are associated with disease and treatment related morbidity. We describe in Chapter 9 the result of a study on the prevalence of reduced bone mineral density in a cross-sectional cohort of patients and correlated bone mineral density findings with disease episodes and cumulative doses of steroids and cyclophosphamide. Finally, the patients' perceptions of the effects of Wegener's granulomatosis and systemic lupus erythematosus on health, function, income, and interpersonal relationships are the topics of Chapter 10. Finally th data are summarized and discussed in Chapter 11. 5

14 Chapter 1 Literature Andrassy K, Erb A, Koderisch J, Waldherr R, Ritz E (1991) Wegener's granulomatosis with renal involvement: patient survival and correlations between initial renal function, renal histology, therapy and renal outcome. Clin Nephrol 35: Balow JE, Fauci AS (1993) Vasculitic diseases of the kidney, polyarteritis, Wegener s granulomatosis, necrotizing and crescentic glomerulonephritis, and other disorders. In: RW Schrier, CW Gottschalk (eds): Diseases of the kidney. 5th Edition. Little, Brown and Company, Boston, Bouroncle BA, Smith EJ, Cuppage FE (1967) Treatment of Wegener's granulomatosis with Imuran. Am J Med 42: Cohen Tervaert JW, van der Woude FJ, Fauci AS, Ambrus JL, Velosa J, Keane WF, et al. (1989) Association Between Active Wegener s Granulomatosis and Anticytoplasmic Antibodies. Arch Intern Med 149: Cohen Tervaert JW, Huitema MG, Hené RJ, Sluiter WJ, The TH, van der Hem GK, Kallenberg CG (1990) Prevention of relapses in Wegener s Granulomatosis by treatment based on antineutrophil cytoplasmic antibody titre. Lancet 336: Cohen Tervaert JW, Goldschmeding R, Elema JD, von dem Borne AE, Kallenberg CG (1991a) Antimyeloperoxidase antibodies in the Churg-Strauss syndrome. Thorax 46: Cohen Tervaert JW, Limburg PC, Elema JD, Huitema MG, Horst G, et al. (1991b) Detection of autoantibodies against myeloid lysosomal enzymes: a useful adjunct to classification of patients with biopsy-proven necrotizing arteritis. Am J Med 91: Cohen Tervaert JW, Stegeman CA, Kallenberg CG (1996) Serial ANCA testing is useful in monitoring disease activity of patients with ANCA-associated vasculitides. Sarcoidosis Vasc Diffuse Lung Dis. 13: Davies DJ, Moran JE, Niall JF, Ryan GB (1982) Segmental necrotising glomerulonephritis with antineutrophil antibody: possible arbovirus aetiology? Br Med J (Clin Res Ed) 285: 606. De'Oliviera J, Gaskin G, Dash A, Rees AJ, Pusey CD (1995) Relationship between disease activity and antineutrophil cytoplasmic antibody concentration in long-term management of systemic vasculitis. Am J Kidney Dis 25: Falk RJ, Jennette JC (1988) Anti-neutrophil cytoplasmic autoantibodies with specificity for myeloperoxidase in patients with systemic vasculitis and idiopathic necrotizing and crescentic glomerulonephritis. N Engl J Med 318: Falk RJ, Hogan S, Carey TS, Jennette JC (1990) Clinical course of anti-neutrophil cytoplasmic autoantibodyassociated glomerulonephritis and systemic vasculitis. The Glomerular Disease Collaborative Network. Ann Intern Med 113: Jennette JC, Falk RJ (1997) Small-vessel vasculitis. N Engl J Med 20;337: Fauci AS, Haynes B, Katz P (1978) The spectrum of vasculitis: clinical, pathologic, immunologic and therapeutic considerations. Ann Intern Med 89: Fauci AS, Haynes BF, Katz P, Wolff SM (1983) Wegener's granulomatosis: prospective clinical and therapeutic experience with 85 patients for 21 years. Ann Intern Med 98: Gaskin G, Pusey CD (1992) Systemic vasculitis. In: JS Cameon, AM Davison, J Grünfeld, DNS Kerr, E Rits (eds): Oxford textbook of clinical nephrology. Oxford University Press, Oxford, Gordon M, Luqmani RA, Adu D, Greaves I, Richards N, Michael J, et al. (1993) Relapses in patients with a systemic vasculitis. Q J Med 86: de Groot K, Reinhold-Keller E, Tatsis E, Paulsen J, Heller M, Nolle B, Gross WL (1996) Therapy for the maintenance of remission in sixty-five patients with generalized Wegener's granulomatosis. Methotrexate versus trimethoprim/sulfamethoxazole. Arthritis Rheum 39: Guillevin L, Cohen P, Gayraud M, Lhote F, Jarrousse B, Casassus P (1999) Churg-Strauss syndrome. Clinical study and long-term follow-up of 96 patients. Medicine (Baltimore) 78: Haubitz M, Koch KM, Brunkhorst R (1998) Cyclosporin for the prevention of disease reactivation in relapsing ANCA-associated vasculitis. Nephrol Dial Transplant 13: Hoffman GS, Kerr GS, Leavitt RY, Hallahan CW, Lebovics RS, Travis WD, et al. (1992) Wegener Granulomatosis: An Analysis of 158 patients. Ann Int Med 116: Jayne DR, Gaskin G, Pusey CD, Lockwood CM (1995) ANCA and predicting relapse in systemic vasculitis. Q J Med 88: Jayne D (2000) Evidence-based treatment of systemic vasculitis. Rheumatology (Oxford) 39: Jennette JC, Falk RJ, Andrassy K, Bacon PA, Churg J, Gross WL, et al. (1994) Nomenclature of systemic vasculitides. Proposal of an international consensus conference. Arthritis Rheum 37: Kallenberg CG, Mulder AH, Tervaert JW (1992) Antineutrophil cytoplasmic antibodies: a still-growing class of autoantibodies in inflammatory disorders. Am J Med. 93:

15 Introduction Nachman PH, Hogan SL, Jennette JC, Falk RJ (1996) Treatment response and relapse in antineutrophil cytoplasmic autoantibody-associated microscopic polyangiitis and glomerulonephritis. J Am Soc Nephrol 7: Norton WL, Suki W, Strunk S (1968) Combined corticosteroid and azathioprine therapy in 2 patients with Wegener's granulomatosis. Arch Intern Med 121: Nowack R, Gobel U, Klooker P, Hergesell O, Andrassy K, van der Woude FJ (1999) Mycophenolate mofetil for maintenance therapy of Wegener's granulomatosis and microscopic polyangiitis: a pilot study in 11 patients with renal involvement. J Am Soc Nephrol 10: Pettersson EE, Sundelin B, Heigl Z (1995) Incidence and outcome of pauci-immune necrotizing and crescentic glomerulonephritis in adults. Clin Nephrol 43: Radis CD, Kahl LE, Baker GL, Wasko MC, Cash JM, Gallatin A, et al. (1995) Effects of cyclophosphamide on the development of malignancy and on long-term survival of patients with rheumatoid arthritis. A 20-year followup study. Arthritis Rheum 38: Reinhold-Keller E, Beuge N, Latza U, de Groot K, Rudert H, Nolle B, et al. (2000) An interdisciplinary approach to the care of patients with Wegener's granulomatosis: long-term outcome in 155 patients. Arthritis Rheum 43: Savage CO, Winearls CG, Jones S, Marshall PD, Lockwood CM (1987) Prospective study of radioimmunoassay for antibodies against neutrophil cytoplasm in diagnosis of systemic vasculitis. Lancet 1: Stegeman CA, Cohen Tervaert JW, Sluiter WJ, Manson WL, de Jong PE, Kallenberg CG (1994) Association of chronic nasal carriage of Staphylococcus aureus and higher relapse rates in Wegener granulomatosis. Ann Intern Med 120: Stegeman CA, Cohen Tervaert JW, de Jong PE, Kallenberg CG, for the Dutch Co-trimoxazole Wegener Study Group (1996) Trimethoprim-sulfamethoxazole for the prevention of relapses of Wegener's granulomatosis. N Engl J Med.335: Stillwell TJ, Benson RC Jr, DeRemee RA, McDonald TJ, Weiland LH (1988) Cyclophosphamide-induced bladder toxicity in Wegener's granulomatosis. Arthritis Rheum 31: van der Woude FJ, Rasmussen N, Lobatto S, Wiik A, Permin H, van Es LA, et al. (1985) Autoantibodies against neutrophils and monocytes: tool for diagnosis and marker of disease activity in Wegener's granulomatosis. Lancet 1: Wiik A (1989) Delineation of a standard procedure for indirect immunofluorescence detection of ANCA. APMIS Suppl 6:

16 Chapter 2 Prevention of relapsing disease in anti-neutrophil cytoplasmic antibody related necrotizing small-vessel vasculitis: the role for autoantibody guided and anti-bacterial treatment Maarten M. Boomsma 1, Coen A. Stegeman 2, Cees G.M. Kallenberg 1, Jan Willem Cohen Tervaert 3 Department of Internal Medicine, 1 Division of Clinical Immunology, 2 Division of Nephrology, University Hospital Groningen, 3 Department of Internal Medicine, Division of Clinical Immunology, University Hospital Maastricht, The Netherlands Disease-modifying therapy in vasculitis. Birkhäuser Verlag, Basel; in press

17 Chapter 2 Summary Immunosuppressive therapy induces disease remission in anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis. Medication is tapered once remission is achieved. Relapses occur frequently during tapering or after treatment is stopped. Here we discuss the literature pertaining to relapses in ANCA associated vasculitis, as well as possible risk factors for relapses, and possible preventive treatment strategies for relapses are discussed. Introduction Within the spectrum of primary vasculitic syndromes, the anti-neutrophil cytoplasmic antibody (ANCA) related syndromes form a distinct group with overlapping features. ANCA related small-vessel vasculitides are potentially life-threatening diseases with high mortality. Prolonged immunosuppressive therapy (>1 year) with cyclophosphamide and steroids is effective in inducing disease remission and preventing early relapses in most vasculitic disorders (Fauci et al., 1978; Fauci et al., 1983; Andrassy et al., 1991; Hoffman et al., 1992; Gaskin et al., 1992; Balow et al., 1993). Continuous use of cyclophosphamide to sustain remission can not be recommended, however, since this treatment regimen is associated with severe and potentially lethal adverse effects such as the occurrence of opportunistic infections and the development of malignancies (Stillwell et al., 1988; Radis et al., 1995). Therefore, cyclophosphamide is tapered or stopped once remission is achieved to prevent adverse effects. Alternatively, azathioprine may be used as maintenance therapy after a remission is induced with cyclophosphamide and steroids (Gaskin et al., 1992). Azathioprine is considered less effective in inducing remission than cyclophosphamide, but its long-term toxicity is much lower (Bouroncle et al., 1967; Norton et al., 1968). The potential of azathioprine as maintenance therapy was recently investigated and compared with cyclophosphamide in a large randomized trial (CYCAZAREM) (Jayne et al., 1997; Jayne et al., 1997; Jayne et al., 2000A; Jayne et al., 2000B). Following induction therapy with oral cyclophosphamide and steroids, maintenance treatment with azathioprine was as effective as the continued use of cyclophosphamide in the prevention of disease relapse during a 15-month follow-up period in this study. Other alternative maintenance therapy regimens, such as methotrexate (de Groot et al., 1996), cyclosporin A (Haubitz et al., 1998), or mycophenolate (Nowack et al., 1999) have been described but have not been tested adequately until now. Since relapses may occur after azathioprine is stopped, prolonged prophylactic treatment with few adverse-effects is desirable. The potential of azathioprine as long-term maintenance therapy after remission is induced is currently investigated in a large randomized controlled trial (REMAIN) in which azathioprine is compared with a strategy in which the patients do not receive any maintenance therapy after 15 months (Jayne et al., 1997). A major disadvantage of prolonged maintenance therapy is that this therapy may expose a substantial number of patients to the unnecessary risk of drug-related morbidity. Some 10

18 Autoantibody guided and antibacterial treatment patients do not suffer from a relapse, whereas in patients with a relapse the interval between remission and occurrence of first relapse may vary from 3 months to 16 years (Hoffman et al., 1992). A cost-benefit argument for exposure to this treatment is, on the other hand, the observation that relapses are associated with substantial morbidity and mortality (Exley et al., 1997). Risk-adjusted treatment by successful prediction of relapses and prevention of relapses by pre-emptive therapy could be of great clinical importance. In this chapter we will review the relevant literature on this subject. What is a relapse and what is remission? Vasculitides are an extraordinary heterogeneous group of inflammatory disorders with diverse clinical manifestations. The vasculitic process can affect blood vessels of any type, size or location, and therefore can cause dysfunction in virtually any organ system. Thus, scoring systems for assessing disease extent and activity are clearly wanted. The purpose of the Disease Extent Index (DEI) (Reinhold-keller et al., 1994) is to assess the extent of vasculitis involvement, rather than its activity per se. At least three groups created indices for measurement of vasculitis activity. We proposed an activity score to measure activity in Wegener's granulomatosis (Kallenberg et al., 1990). Subsequently, the Birmingham Vasculitis Activity Score (BVAS) (Luqmani et al., 1994) and the Vasculitis Activity Index (VAI) (Whiting-O Keefe et al., 1999) were designed to measure the level of activity in patients with all forms of active systemic necrotizing vasculitis. All three indices are valuable in assessing the extent and severity of disease, but have their limitations in defining a relapse or remission. In the literature, the definition of a relapse of vasculitis varies between studies. In many studies, no (Fauci et al., 1983; Hoffman et al., 1992) or only a rough description is given such as "re-emerging of clinical symptoms of vasculitis after a period of complete remission" (Gordon et al., 1993; Davenport et al., 1995; Guillevin et al., 1999; Kyndt et al., 1999; Reinhold-Keller et al., 2000). In only a few studies precise and well-defined criteria for the definition of a relapse have been given (Cohen Tervaert et al., 1989; Stegeman et al., 1994; Nachman et al., 1996; Stegeman et al., 1996; Westman et al., 1998; Boomsma et al., 2000). The occurrence of relapses In many studies data on relapses in patients with various forms of ANCA associated smallvessel vasculitis have been published (Fauci et al., 1983; Hoffman et al., 1992; Gordon et al., 1993; Davenport et al., 1995; Guillevin et al., 1999; Kyndt et al., 1999; Reinhold-Keller et al., 2000; Cohen Tervaert et al., 1989; Stegeman et al., 1994; Nachman et al., 1996; Westman et al., 1998; Boomsma et al., 2000; Kerr et al., 1993; De Oliviera et al., 1995). The number of patients suffering from one or more relapses during follow-up, after achieving complete remission, ranges from 25-81%. Differences in patient selection, duration of follow-up, definition of disease activity, and immunosuppressive treatment protocols may underlie the 11

19 Chapter 2 large variability in relapse rates. Hoffman et al performed the largest observational study (Hoffman et al., 1992). In this study, 158 patients with Wegener's granulomatosis were studied from diagnosis, during a follow-up of up to 24 years. Cyclophosphamide was continued for at least 1 year after the patient achieved complete remission, and then tapered every 2 to 3 months. With this treatment regimen, 66% of the patients with Wegener's granulomatosis with over 5 years of follow-up after diagnosis experienced at least one relapse, whereas more than 80% of the patients with over 10 years of follow-up experienced one or more relapses. In a recent study by Reinhold-Keller et al, 99 out of 155 (64%) patients with Wegener's granulomatosis with a median follow-up of 7 years (ranging from 0.3 to 27.3 years) suffered from one or more relapses during follow-up, 50 after complete remission, 49 after partial remission (Reinhold-Keller et al., 2000). In this study, after partial or complete remission was achieved, cyclophosphamide treatment was switched to long-term maintenance regimens with co-trimoxazole in patients with normal renal function who were not taking steroids, methotrexate in patients in partial remission with restored renal function or azathioprine in patients with impaired renal function. Gordon et al studied 150 consecutive patients with various forms of systemic vasculitis presenting over a 10-year period (Gordon et al., 1993). The follow-up ranged from 1 month up to 9.75 years. Twenty-seven patients died within 3 months of diagnosis. Of the remaining 123 patients, 42 (34%) had one or more relapses during follow-up. Gordon et al found that the relapse risk was diagnosis dependent. Patients with limited Wegener's granulomatosis (without renal disease) and generalized Wegener's granulomatosis (with renal disease) showed a higher risk of suffering from a relapse than patients with other forms of vasculitis such as microscopic polyangiitis. The relapse rates of patients with limited Wegener's granulomatosis and generalized Wegener's granulomatosis were 52% (median time to relapse 18 months) and 44% (median time to relapse 42 months), respectively, whereas the relapse rate of patients with microscopic polyangiitis was only 25% (median time to relapse 24 months). Nachman et al studied 97 patients with microscopic polyangiitis and idiopathic necrotizing crescentic glomerulonephritis for a mean of 2.7 years (Nachman et al., 1996). Of the 75 patients that went into remission, 22 (29%) suffered a relapse which occurred within 18 months of the end of therapy. Guillevin et al studied 96 patients with Churg-Strauss syndrome (Guillevin et al., 1999). Of their 86 patients coming into remission, 22 (26%) suffered a relapse that occurred after a mean interval from remission to relapse of 5.8 years. Geffriaud-Ricourd et al studied the course of the disease in 76 patients with various forms of ANCA associated vasculitis for a mean period of 2.5 years (Geffriaud-Ricouard et al., 1993). Relapses occurred in 36% of patients with Proteinase-3 (PR3)-ANCA PR3-ANCA and 20% of patients with myeloperoxidase (MPO)-ANCA. Franssen et al studied 92 patients with ANCA associated vasculitis and in this study patients with PR3-ANCA associated vasculitis had a significantly higher relapse rate (22%) than patients with MPO-ANCA associated vasculitis (7%) (follow-up not stated) (Franssen et al., 1998A). Westman et al studied

20 Autoantibody guided and antibacterial treatment patents with Wegener's granulomatosis and microscopic polyangiitis with biopsy proven renal involvement for a mean of 5.3 years and they also found a tendency to higher relapse rates in patients with PR3-ANCA than in those with MPO-ANCA, however this was not statistically significant (Westman et al., 1998). At our institution, several studies were published with data on relapses in patients with Wegener's granulomatosis (Table 1). In these studies, patients were included when remission was induced after initial diagnosis or relapse (Cohen Tervaert et al., 1989; Boomsma et al., 2000), or inclusion occurred irrespective of disease activity (Stegeman et al., 1994). Therefore, these data are not comparable with studies described above, in which patients were studied from onset of disease. Table 1 The occurrence of relapses in patients with ANCA associated vasculitis Reference n. Patients with Number of Follow-up (years) Relapses / (a) relapse(s) relapses Median (range) years Cohen Tervaert et al (1989) (34%) (1.3) 0.26 / year Stegeman et al (1994) (40%) ( ) 0.18 / year Boomsma et al (2000) (37%) ( ) 0.18 / year Risk factors for relapses The literature pertaining to risk factors and preventive treatment strategies for relapses is largely restricted to patients with ANCA associated vasculitis, especially to patients with (PR3-ANCA positive) Wegener's granulomatosis. Whether findings are also applicable to patients with MPO-ANCA positive vasculitis or other forms of vasculitis remains largely unknown. Anti Neutrophil Cytoplasmic Antibodies (ANCA) as a risk factor for relapses ANCA were first described in 1982 by Davies et al in a few patients with necrotizing crescentic glomerulonephritis (Davies et al., 1982). In 1985, van der Woude et al showed that ANCA producing a cytoplasmic staining pattern on ethanol-fixed neutrophils using the indirect immunofluorescence technique (IIF) are a sensitive marker for Wegener's granulomatosis (van der Woude et al., 1985). Subsequently, ANCA producing a perinuclear cytoplasmic staining pattern (P-ANCA) by IIF were described in patients with idiopathic necrotizing crescentic glomerulonephritis, microscopic polyangiitis, and Churg Strauss syndrome. PR3 and MPO were identified in these patients as the principal target antigens of C-ANCA and P-ANCA, respectively, in those diseases (Falk et al., 1988; Cohen Tervaert et al., 1990A). Although there is clinically considerable overlap, PR3-ANCA associated vasculitis predominantly relates to patients who have vasculitis that is associated with upper respiratory tract disease (Wegener's granulomatosis), whereas MPO-ANCA associated 13

21 Chapter 2 vasculitis mainly relates to patients with idiopathic necrotizing crescentic glomerulonephritis and microscopic polyangiitis with limited extrarenal organ involvement (Franssen et al., 2000). Figure 1 Disease-free interval and C-ANCA status. Disease-free interval according to the course of C-ANCA during the study (n = 54). The time of disease-free interval was counted from the beginning of the most recent period of disease activity (either initial diagnosis or relapse). (C- ANCA-negative versus intermittently and persistently C-ANCA-positive, P < 0.001). Dashed line = C-ANCA-negative (n = 21); broad line = intermittently C-ANCA positive (n = 21); thin line = persistently C-ANCA-positive (n = 12). Reprinted from Stegeman et al (1994) with permission of the publisher. Van der Woude et al suggested in 1985 that levels of C-ANCA as measured by IIF parallel disease activity (van der Woude et al., 1985). Indeed, in patients with newly diagnosed disease high levels are observed and these levels decline during immunosuppressive treatment and become undetectable in many cases (Cohen Tervaert et al., 1989). In some patients, however, ANCA levels are persistently detectable without any sign / symptom of active disease. The persistence of ANCA has been identified as a risk factor for an ensuing relapse by several groups (Figure 1) (Stegeman et al., 1994; De Oliviera et al., 1995; Jayne et al., 1995). Persistent positivity may also be a risk factor for the development of end stage renal failure in the absence of signs of a relapse of disease as was found in patients with MPO- ANCA associated necrotizing crescentic glomerulonephritis (Franssen et al., 1998B). Furthermore, we noted that rises in C-ANCA titer as detected by IIF often precedes disease activity when ANCA levels are serially measured. In our first study, 17 relapses in 35 patients were observed and all (100%) were preceded by a significant rise in C-ANCA titer (Cohen Tervaert et al., 1989). Furthermore, out of 22 C-ANCA rises, 17 (77%) were followed by a relapse. These early findings suggested that serial measurement of ANCA titers is useful in the follow-up of patients with Wegener's granulomatosis. After this study, several other groups have reported on the clinical utility of serial measurements of ANCA as detected by IIF (Table 2). Differences in frequency of ANCA testing, use of immunosuppressive maintenance therapy, and methodology of ANCA testing may underlie the large variability in results. In a pooled analysis of published data from the studies listed in Table 2 (Davenport et al., 1995; Kyndt et al., 1999; Cohen Tervaert et al., 1989; Boomsma et al., 2000; Kerr et al., 14

22 Autoantibody guided and antibacterial treatment 1993; Egner et al., 1990; Cohen Tervaert et al., 1990B; Chan et al., 1993), 59% of relapses were preceded by rising titers, whereas only 48% of rises in ANCA titers as measured by IIF were followed by a relapse. In our recent prospective study on a large cohort of 85 patients with C-ANCA positive Wegener's granulomatosis, 33 relapses were observed and 17 (52%) were preceded by a significant rise in C-ANCA titer (IIF). Furthermore, of the 30 significant rises in C-ANCA (IIF), 17 (57%) were followed by a relapse (Figure 2) (Boomsma et al., 2000). Table 2 Relationship between relapses and rises in ANCA as detected by indirect immunofluorescence (IIF) Reference ANCA staining Relapse preceded by Rise in ANCA n. pattern (IIF) a rise in ANCA followed by a relapse Cohen Tervaert et al (1989) 35 C-ANCA 100% 77% Egner & Chapel et al (1990) 10 C-ANCA 100% 75% Cohen Tervaert et al (1990B) 58 C-ANCA 90% 82% Chan et al (1993) 10 N.R. 82% 65% Kerr et al (1993) 68 C-ANCA 24% 56% Davenport et al (1995) 37 C- / P-ANCA 43% 23% Kyndt et al (1999) 19 C-ANCA N.R. 57% Boomsma et al (2000) 85 C-ANCA 52% 57% N.R. = Not reported; C-ANCA = cytoplasmic staining pattern; P-ANCA pattern = perinuclear staining pattern. Disease-free (%) ELISA IIF Time (months after titer rise) Figure 2 Percentage of patients with Wegener s granulomatosis who did not experience disease relapses in the indicated time period after a rise in antineutrophil cytoplasmic antibodies as measured by either indirect immunofluorescence ( IIF; n = 30) or antigen-specific enzyme-linked immunosorbent assay (o ELISA; n = 38). The numbers above the horizontal axis indicate the number of patients who were still at risk for a relapse at 6, 12, 18, 24, and 30 months after the rise in antibody levels as detected by ELISA (upper numbers) or IIF (lower numbers). Reprinted from Boomsma et al (2000) with permission of the publisher. 15

23 Chapter 2 The IIF technique has the disadvantage that levels of ANCA are difficult to quantify precisely (Kerr et al., 1993; Hagen et al., 1993). Solid phase assays using purified antigens are better suited to quantify specific antibody levels. Four studies using serial determination of ANCA by ELISA have been published and are listed in Table 3 (Kyndt et al., 1999; Boomsma et al., 2000; De Oliviera et al., 1995; Jayne et al., 1995). Substantial differences are noted in the methodology of ANCA testing. De'Oliviera et al (De Oliviera et al., 1995) used an extract of azurophilic granules as antigen to measure ANCA levels whereas in the other studies purified antigens (PR3 or MPO) were used (Kyndt et al., 1999; Boomsma et al., 2000; Jayne et al., 1995). Furthermore, patients with different forms of ANCA-associated vasculitis were studied, i.e., either only patients with Wegener's granulomatosis (Boomsma et al., 2000), patients with Wegener's granulomatosis and microscopic polyangiitis (Jayne et al., 1995), patients with Wegener's granulomatosis, microscopic polyangiitis and renal limited vasculitis (Kyndt et al., 1999), or patients with Wegener's granulomatosis, microscopic polyangiitis, renal limited vasculitis and Churg-Strauss syndrome (De Oliviera et al., 1995). Jayne et al found rises in ANCA prior to or at the moment of a relapse in 74% of the patients; in 45% of the cases those rises preceded clinical symptoms (Jayne et al., 1995). In this study, patient follow-up was restricted to the first year after diagnosis. In the study of Kyndt et al, 73% of MPO-ANCA positive patients had a rise in ANCA prior to or at the moment of relapse (in 55% of the cases rises preceded clinical symptoms), whereas only 33% of the PR3-ANCA positive patients had a rise in ANCA as detected by ELISA prior to or at the moment of relapse (preceding clinical symptoms in 20%) (Kyndt et al., 1995). Unfortunately, in this latter study no precise definitions were given for ANCA rises and inter-assay variation was not reported. Furthermore, the patients were sampled with intervals as long as 3 months, which might explain why many rises in ANCA were found at the time of the relapse instead of prior to the relapse. In our study, we found that 82% of the patients with PR3-ANCA associated Wegener's granulomatosis had a rise in ANCA as detected by ELISA prior to or at the moment of a relapse (preceding clinical symptoms in 66%), and that 71% of the PR3- ANCA rises were followed by a relapse (Figure 2) (Boomsma et al., 2000). Furthermore, 75% of the relapses in patients with MPO-ANCA associated Wegener's granulomatosis were preceded by a rise in MPO-ANCA, and all MPO-ANCA rises were followed by a relapse. There is, however, great variability in time lag between the detection of a rise in ANCA and the occurrence of a relapse. In the study of Jayne et al, a rise in ANCA preceded the clinical relapse by 7.8 weeks (standard deviation 6.5 weeks) in 57% of the patients with a relapse, and in 17% of their patients ANCA rose at the time of a relapse (Jayne et al., 1995). Although, during extended follow-up, a relapse occurred in 71% of patients after a rise in PR3-ANCA (ELISA) in our prospective study, only 39% of the patients with such a rise had a relapse of their disease within 6 months after the rise, and 59% of the patients within 12 months (Boomsma et al., 2000). The median time between the detection of a rise in PR3-ANCA and a 16

24 Autoantibody guided and antibacterial treatment relapse was 167 days (range days) and the interval between a rise in MPO-ANCA and a relapse ranged from 121 to 217 days. Overall, it can be concluded that relapses are frequently preceded by increases of ANCA, and that ELISA is a more sensitive method than IIF in predicting disease activity. However, ANCA increases are not invariably followed by a relapse (Table 2 and 3). Why are rising ANCA titers not always followed by a relapse? It has been reported that switching from cyclophosphamide to azathioprine therapy may result in a rise in ANCA that is not followed by a relapse (Jayne et al., 1995). Another explanation could be that patients with a rise in ANCA may have subtle signs of disease activity but do not fulfill the criteria for a relapse. In our study, we observed a rise in PR3-ANCA (ELISA) that was not followed by a relapse in 11 patients (Boomsma et al., 2000). These 11 patients had slightly higher C-reactive protein levels and erythrocyte sedimentation rates during the first 3 months after an ANCA rise than 11 age and sex matched patients with Wegener s granulomatosis without a rise in ANCA in the same period (Figure 3) [unpublished data]. Therefore, we hypothesize that these patients may have suffered from low-grade disease activity after an ANCA rise. Table 3 Relationship between relapses and rises in ANCA as detected enzyme linked immunosorbent assay (ELISA) Reference ANCA specificity Relapse precede by a rise in ANCA Rise in ANCA followed by a relapse n. de Oliviera et al (1995) 56 Extract 41% 62% Jayne et al (1995) 60 N.R. 74% 79% Kyndt et al (1999) 17 PR3 33% 59% 19 MPO 73% 79%. Boomsma et al (2000) 85 PR3 81% 71% 15 MPO 75% 100% N.R. = Not reported; PR3 = proteïnase 3; MPO = myeloperoxidase; extract = extract of azurophilic granules. Since high ANCA levels may be found in patients during clinical remission, we postulate that differences in qualities of antibodies may be important with respect to the development of a relapse. Previously, it was found that IgG isolated from serum samples of patients with active generalized Wegener's granulomatosis, when incubated with donor granulocytes, induced significantly higher levels of the respiratory burst compared with IgG isolated from patients in remission (Mulder et al., 1995). Changes in the capacity to induce the respiratory burst were not related to ANCA levels as measured by IIF and/or ELISA, but were related to the IgG3 ANCA / total IgG ANCA ratio. Furthermore we demonstrated in a small retrospective study that rises in IgG3 subclass of ANCA as measured by ELISA were a more specific predictor of relapses than rises of C-ANCA as measured by IIF (Cohen Tervaert et al., 1994). However, in our recent large prospective study we found that additional measurement of levels of IgG3 17

25 Chapter 2 subclass of PR3-ANCA was of little benefit (Boomsma et al., 2000). Rises in levels of IgG3 subclass of PR3-ANCA increased the positive predictive value of a rise in ANCA, but decreased the sensitivity for a relapse. Anti-PR3 antibodies interfere with the complexation of PR3 with α-1 antitrypsine (van der Wiel et al., 1992). In a longitudinal study it was shown that disease activity in patients with Wegener's granulomatosis correlates with the capacity of the antibodies to inhibit complexation rather than with the titer of the anti-pr3 antibodies as detected by either IIF or ELISA (Dolman et al., 1993). Anti-PR3 antibodies also interfere with PR3 elastinolytic and proteolytic activity (van der Wiel et al., 1992). Inhibitory activity of the antibodies changes during the course of the disease, reflecting disease activity better than the absolute anti-pr3 titer (Daouk et al., 1995). All these studies support the idea that not only the quantity, but also the quality of ANCA might influence the pathogenic potential of the antibodies p = 0.08 p = Figure 3 Area under the curve (AUC) of C- reactive protein (CRP) levels (mg/l) and erythrocyte sedimentation rate (ESR) AUC CRP AUC ESR (mm/hour) during a 3 months period in patients with a rise in PR3-ANCA (T+) not followed by a relapse of disease activity as compared to matched patients without a rise (T-). Patients with a rise in PR3-ANCA had slightly higher C-reactive protein levels 0 T+ CRP T- CRP T+ ESR T- ESR 0 (P=0.08) and erythrocyte sediment rates (P=0.06) as compared to the controls. Infections as a risk factor for relapses Patients with Wegener's granulomatosis frequently have symptoms of respiratory tract infections at the time of an ANCA rise (Cohen Tervaert et al., 1990B), at the onset of the disease, or preceding the occurrence of a relapse (Davies et al., 1982; Pinching et al., 1980; Ronco et al., 1983). So, does infection trigger relapses in Wegener's granulomatosis? Previously, we found that 9 out of 23 patients with a relapse had an upper-airway infection during a 6 months period preceding the relapse. However, infections were not specifically associated with relapses since many infections were not related to a relapse (Stegeman et al., 1994). This was also found in another longitudinal study of 81 patients with Wegener's granulomatosis (Stegeman et al., 1996). We conclude from these studies that infections are not important triggers for relapses although it is possible that self-limiting viral or bacterial infections have been missed in patients. 18