Managing Acute Medical Problems, Birmingham Vasculitis. David Jayne. University of Cambridge

Transcription

1 Managing Acute Medical Problems, Birmingham 2016 Vasculitis David Jayne University of Cambridge

2 Disclosures Astra Zeneca, Aurinia, BIOGEN, Boehringer, Chemocentryx, Genzyme/Sanofi, GSK, Lilly, Medimmune, Merck Serono, Roche/Genentech Research grants, consultancy, honoraria

3 Case history: 18 year old, male Admitted: severe central abdominal pain Fevers, 12 kg weight loss Background: Cholecystectomy Severe asthma Bloods: CRP 160 WCC 16.2 (neutrophils 11.73, eosinophils 2.41)

4 Histology slides courtesy of Dr Penny Wright, Consultant Histopathologist

5 Renal arteriogram segmental occlusion of intrarenal branch arteries with peripheral infarction.

6 Immunosuppression enhanced methylprednisolone and cyclophosphamide (D6 post-admission) IV Methyl pred. 500mg x3 IV Cyclophosphamide

7 Cardiac MRI with gadolinium patchy signal enhancement in the dilated LV myocardium Signal abnormality in the lower septum and inferior wall of the LV

8 Further immunosuppression methylprednisolone and Rituximab (D15 post-admission) IV Methyl pred. Cyclophosphamide MP 500mg x3 Rituximab

9 Persistent eosinophilia with cardiac instability Hypotensive, runs of non-sustained ventricular tachycardia (VT) IVIg

10 Papworth referral Declined for mechanical support or cardiac transplant

11 Further immunosuppression with methylprednisolone and Alemtuzumab (D28 post-admission) IVIG MP 500mg x3 Alemtuzumab CYC RTX

12 Back at University Clinical Progress

13 Vasculitis syndromes Primary Autoimmune Secondary Drug Infection Malignancy Immune (SLE) Other Behcet s Autoinflammatory Small print

14 Jennette et al, Arthritis Rheum 2012

15 GPA (Wegener s) triad

16 ANCA vasculitis overlapping phenotypes GPA / Wegener s Respiratory tract Granulomata 70% renal PR3 >> MPO 55yr EGPA MPA 90% renal MPO > PR3 65yr Incidence 19/million/yr Prevalence 250/million Eosinophilia Neuropathy Cardiomyopathy 40% MPO

17 Suspicion

18 Small Vessel Renal Vasculitis Rapidly progressive glomerulonephritis rising creatinine + crescents on biopsy (oliguria) Urine haematuria with proteinuria Imaging kidneys normal size

19 Diagnosis

20 Approach to diagnosis Clinical features Imaging/serology Histology Diagnosis Drives, triggers and mimics Period of observation

21 Treatment

22 B cell depleting monoclonal antibody Ri - tu xi - mab

23 MAINRITSAN : major relapse Guillevin, et al. N Engl J Med. 2014

24 Relapse after two years repeat dose rituximab 24 month RTX treatment 50% 26 months Alberici et al, Rheumatology 2014

25 When is rituximab preferred to cyclophosphamide? Induction to avoid cyclophosphamide (fertility risk) Relapsing disease Especially PR3-ANCA + High cyclophosphamide exposure/reduce cancer risk Refractory disease Other? Infection, malignancy Intensive care unit Ntatsaki et al, Rheumatology 2014

26 Rituximab and granulomatous GPA manifestations Pe-RTX +3 months b. Martinez del Pero et al, Clin Otolaryngol 2009

27 Severe disease Rapidly progressive glomerulonephritis Diffuse alveolar haemorrhage

28 Plasma exchange and prevention of end stage renal disease (creatinine > 500μmol/L at diagnosis) P=0.008 Walsh et al, Kidney International 2013

29 Plasma exchange, meta-analysis death/esrd Study ID RR (95% CI) Weight Rifle (1980) Mauri (1985) Glockner (1988) Pusey (1991) Cole (1992) Guillevin (1997) Zauner (2002) Jayne (2007) Szpirt (2008) Overall (I-squared = 0.0%, p = 0.662) 0.57 (0.25, 1.33) 0.83 (0.45, 1.56) 0.86 (0.29, 2.56) 1.15 (0.69, 1.91) 1.00 (0.36, 2.79) 0.60 (0.29, 1.24) 1.18 (0.61, 2.28) 0.73 (0.52, 1.03) 0.50 (0.19, 1.33) 0.81 (0.66, 1.00) Favours Plasma Exchange Favours No Plasma Exchange Walsh et al, Am J Kid Dis 2010

30 Co-morbidities

31 Survival and ESRD in AAV Patient survival Renal survival 1 year - 84% 5 years 73% 5 years 80% Flossmann et al, Ann Rheum Dis 2010

32 Causes of death Multivariable analysis Infection Leucopenia GFR Cumulative CYC 1.2 p< p< p= p=0.04 Little et al, Ann Rheum Dis 2009 Flossmann et al, Ann Rheum Dis 2010

33 Relapse 50%, 7years Walsh et al, Arthritis Rheum 2011

34 Malignancy risk Heijl et al, Ann Rheum Dis 2011

35 Prevalence of damage items (VDI) Disease related Treatment related Robson et al, Rheumatology 2014

36 Guidelines for the Management of adults with ANCA Associated Vasculitis Ntatsaki et al, Rheumatology 2014

37 Improvement in ANCA vasculitis survival? Diagnosis after 2000 Diagnosis before 2000 p = 0.01 Hruskova Z et al, for the Czech Vasculitis Registry

38 Take home Suspicion Unexplained inflammatory disease Constitutional prodrome Diagnosis Integrate Features, Imaging, Serology, Histology Individual tests unreliable Drives, triggers & mimics Management Multi-disciplinary, guidelines, biologics Seek help

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40 January 11-13, 2017