Management of scleroderma renal crisis. Voon Ong Senior Clinical Lecturer Royal Free Hospital and UCL Medical School, London, UK

Transcription

1 Management of scleroderma renal crisis Voon Ong Senior Clinical Lecturer Royal Free Hospital and UCL Medical School, London, UK

2 Overview Presentation of SRC Diagnosis and management Pathogenesis Predictors of outcome Differential diagnosis Future therapies

3 Scleroderma renal crisis Rapidly progressive renal impairment New onset accelerated phase hypertension Headaches Visual disturbances Encephalopathy with seizures flash pulmonary oedema fevers / malaise pericardial effusion +/- MAHA Hyper-reninaemia 1 year survival improved from 15% to 76% with ACE inhibitors (Steen et al, 1990) Grade IV retinopathy Schistocytes - MAHA

4 Pathogenesis of scleroderma renal crisis CD45 Interstitial fibrosis Lymphocytosis Background nephropathy Chronic vasculopathy Acute vascular event vwf asma Endothelial cell activation Growth factor release Smooth muscle cell proliferation Trostle DC, et al. Arthritis Rheum Mar;31(3): Shanmugam VK, Steen VD. Int J Rheumatol. 2010; 17.

5 Pathogenesis of scleroderma renal crisis CD34 asma Proliferative vasculopathy Glomerular ischaemia Thrombosis Hyperplasia of juxtaglomerular apparatus Sustained activation of renin-angiotensin axis Fibrinoid necrosis

6 Molecular markers of proliferative vasculopathy in renal crisis asma VEGF TGFb1 ET-1 Penn et al. QJM 2013; 106:

7 Algorithm for management of SSc renal crisis Follow up: Renal function improvement may continue for up to 24 months after renal crisis Antihypertensive requirements often fall Other aspects of disease may improve Occult cardiac disease may manifest SSc stage and subset BP elevated Renal impairment Renal failure Education, BP monitoring, avoid precipitants ACEI (or ARB) Close observation renal function, check for MAHA and endorgan disease Hospital admission increase ACEI/ARB, additional oral antihypertensive?prostacyclin infusion, close monitoring, renal support Recovery Long term renal replacement Transplant Post-transplant surveillance

8 Management of scleroderma renal crisis Current RFH protocol Angiotensin converting enzyme inhibition especially if renal function deteriorating. Later add ARB. iloprost continuous infusion titrated to blood pressure Additional blood pressure lowering (20mm systolic per day). additional oral antihypertensive agents (doxazocin, diltiazem) nitrate infusion/ ventilatory support for pulmonary oedema Renal biopsy when BP and clotting normal Careful haemodynamic monitoring and HDU nursing. oesophageal Doppler assessment of SVR may be helpful Renal support intermittent haemodialysis or CVVHF or peritoneal dialysis No clear benefit from plasma exchange

9 ACEi efficacy in SRC First report of successful Rx with ACEi 1 No randomised controlled studies of benefit Comparison with historical controls suggests major therapeutic gain 2 Single centre case-control study 108 patients % 1 year survival without ACEi 76% 1 year survival with ACEi NB cohort effect Angiotensin II receptor blockade may be useful but anecdotally less effective than ACEi 3. Additive effect unproven. 1. Lopez-Ovejero, et al. N Engl J Med 1979; 300: Steen, et al. Ann Intern Med 1990; 113: Caskey et al Lancet 1997;349:620

10 Role for preventative strategy using ACEi in scleroderma renal crisis ACEi have no benefit for RP or digital ulcers - QUINS trial 1 Use of ACEi/ATII blockers prior to SRC associated with trend towards worse outcome 2,3 Pooled data analysis from two studies gives OR 2.4 ( CI) and p=0.059 Chi Squared value Recent prospective international cohort study raised similar concerns No dialysis Dialysis and recovery Dialysis without recovery Total Pre-SRC ACEi/ATII 7 (35%) 3 (15%) 10 (50%) 20 No pre-src ACEi/ATII 20 (42%) 14 (29%) 14 (29%) 48 Total Odds ratio Odds ratio 95% CI Fishers exact test p value Glidden, et al. Arthritis Rheum 2007; 55: Penn, et al. QJM 2007; 100: Teixeira, et al. Ann Rheum Dis 2008; 67: Penn and Denton. Curr Opin Rheum 2008; 20: Hudson et al. Int J Rheumatol. Epub 2010.

11 Scleroderma renal crisis (SRC) at the Royal Free Hospital 110 patients with hypertensive SRC identified Mean age 50.7 years 79% female Duration of disease 22% had SRC as presenting feature of SSc 66% within 1 year of presentation with SSc Subset 22% lcssc (1.9% of those under follow-up) 78% dcssc (16% of those under follow-up) Serology 50% RNA polymerase antibodies (odds ratio 11) 2% ACA (odds ratio 0.05) 59% received steroid in 1 month prior to SRC Mean GFR prior to SRC 77 ml/min Penn H, et al. QJM 2007;100:

12 Rationale for renal biopsy in SRC Exclude other diagnosis Glomerulonephritis Interstitial & tubular nephritis Thrombotic thrombocytopenic purpura Prognostic benefit Acute vascular changes associated with requiring permanent dialysis 1 OR 6.6 (p=0.025, n=52) Chronic changes (arteriolar hyalinosis) not associated with outcome Corroborative data from recent North American series 2 1 Penn H, et al. Q J Med 2007;100: Batal et al. Hum Pathol 2009; 40:332-40

13 Glomerular disease in systemic sclerosis from RFH database (n=14) Autoimmune serology 13/14 ANA positive 3/14 anti-topoisomerase-1 3/12 anti-rna polymerase I/III 8/14 U1-RNP positive 10/14 dsdna and/or Sm positive 6/14 low serum complement (C3, C4) Biopsy 1 typical SRC with good outcome Biopsy 2 increased proteinuria and worsening renal function

14 ANCA as a serological marker of renal SSc Marker for vasculitis and glomerulonephritis PR3, MPO and atypical reactivity observed Case reports and small series highlight renal vasculitis in SSc associated with ANCA Endo H et al.j Rheumatol. 1994;21: Kamen DL et al. J Rheumatol. 2006;33: Association with previous D-penicillamine therapy reported GS, Khan IH, Simpson JG, Rees AJ.Am J Kidney Dis. 1997;30: Important serological clue for urgent renal biopsy in clinical context RFH y early dcssc Anti-PR3 > 600 Anti-U3RNP Haematuria Normal renal function Derrett-Smith, et al. Rheumatology 2013; 52:

15 Change in CrCl (ml/min/year) Alive patients remaining on dialysis after SRC (%) Renal recovery after SRC 42% long term dialysis 24% dialysis and recovery 34% no dialysis Recovery occurs up to 2 years after SRC egfr improves for at least 4 years % cases alive at 3 years are off dialysis Duration of dialysis mean = 711 days median 11 months Time after SRC (years) 0-10 Penn H, et al. QJM 2007;100: Time after SRC (years)

16 Age at SRC (years) Diastolic BP (mmhg) Factors affecting renal outcome Presenting BP (systolic and diastolic) Mean = 103 (94-113) ANOVA p < Mean = ( ) Mean = 114 ( ) Age (if dialysis is required) Presenting creatinine Lower in those not requiring dialysis No dialysis Mean = % CI ( ) Dialysis Recovery Mean = % CI ( ) Dialysis No recovery Mean = % CI ( ) ANOVA p < Penn H, et al. QJM 2007;100: No dialysis Dialysis Recovery Dialysis No recovery

17 Survival for SRC stratified by renal outcome Survival at: 1 year = 82% 3 years = 71% 10 years = 47% Poorer prognosis in males Survival by renal outcome (%) 100 p < Temporary dialysis No dialysis required Permanent dialysis NS Time (years) Penn H, et al. QJM 2007;100:

18 Proportion of patients discontinuing dialysis (%) Mean time to recovery (months) Proportion of patients on dialysis (%) Differential prognosis for ARA specificity in SRC All SRC n=150 Dialysis n=86 No Dialysis n=60 ARA positive ARA negative Recovery n=56 No Recovery n=29 Death <6 mths n=5 ARA positive Log-Rank = ARA positive ARA negative ARA negative ARA positive ARA negative Lynch BM, Denton CP et al, ACR San Diego 2013

19 Renal transplantation in SSc Small series in literature mainly abstracted from registry data Recurrence reported in up to 5% grafts Chronic allograft rejection and recurrent SSc may be difficult to distinguish Decision should be delayed for at least 18 months from SRC Poor outcome of long-term dialysis in SSc 35% alive at 3 yrs (Chang and Spiera, 1999) 3-year survival 55% on waiting list, 80% after transplant (Gibney et al, 2004)

20 Endothelin blockade in SRC BIRD-1 An ETRB open-label study SMA of bosentan in patients with SSc renal crisis to test safety and see if outcome is better than standard treatment Investigators: Chris Denton, Henry Penn, Aine Burns CD34 TGFb1 ET-1 ETRA Penn et al. QJM 2013; 106:

21 Median (range) BP at presentation Median (range) serum creatinine at presentation (micromol/l) Dialysis Summary of renal outcomes for BIRD-1 and recent historic comparator cohort egfr median (range) ml/min for cases not on dialysis BIRD-1 cohort (n=6) 194/118 ( /90-140) cohort (n=49) 195/114 ( /80-180) 185 (94-251) 191 ( ) Ever 3/6 (50%) 34/49 (69%) At 12 mths 2/5 (40%) 25/49 (51%) At 3 mths 66 (43-85) 31 (21-83) At 6 mths 68 (59-107) 36.5 (19-66) At 12 mths 72 (62-107) 41 (23-70) Mortality at 1 year 1/6 (16%) 6/49 (12%) Penn et al. QJM 2013; 106:

22 Novel approaches in SRC case reports Izzezdine H et al Endothelin receptor antagonism-based treatment for scleroderma renal crisis. Am J Kidney Dis 2013;62:394-5 Sustained effect with combination Bosentan and Ramipril Dhaun N et al Endothelin receptor antagonism and renin inhibition as treatment options for scleroderma kidney. Am J Kidney Dis 2009;54: Benefit with Sitaxsentan and Aliskiren

23 Key messages SSc renal crisis Risk factors can be identified dcssc corticosteroid > 20mg/day early disease tendon friction rubs anti-rna pol III rapidly progressive skin Good outcome predictors severe hypertension absence of acute vascular damage on biopsy Patients may recover renal function up to 24 months after SRC Renal transplantation is an option Prophylactic benefit of ACEI/ARB is unproven ANCA or SLE serology suggest alternative pathology

24 Dr Henry Penn Dr Svetlana Nihtyanova Dr Bernadette Lynch Dr Richard Stratton Dr Edward Stern Dr Sandra Guerra Korsa Khan Dr Aine Burns Prof Alan Salama Dr Mark Harber Dr Ed Kingdon Dr Chris Bunn Jenny Parker Prof Chris Denton Dr Carmen Fonseca Prof David Abraham Prof C Black Acknowledgements Renal Department RFH Immunology Department RFH