| Part 1 Prognosis and risk factors of Anti-neutrophil cytoplasmic antibody-associated vasculitis in patients with renal injury Objective The most frequently involved organs of ANCA associated vasculitis(AAV)are lung and kidney,and kidney involvement is the main factor threatening the life of patients.The risk of progression to end-stage renal disease and death of patients with renal involvement is very high.The purpose of this study was to retrospectively analyze the risk factors of progression to end-stage renal disease in patients with AAV renal impairment.Methods One hundred and thirteen consecutive patients newly diagnosed with AAV at the Institute of Nephrology,Tongji hospital affiliated to Huazhong University of Science and Technology,from 2012 to 2019,were analyzed retrospectively.According to the different response to treatment,the renal outcome was divided into renal remission,renal recurrence and end-stage renal disease.Among them,renal remission was defined as stable or improved renal function,urinary RBC < 10/HPF,and other extrarenal manifestations caused by vasculitis disappeared.The definition of renal recurrence is that after renal remission,the number of new hematuria or red blood cell type is increased,and the level of serum creatinine related to vasculitis activity is increased.The risk factors of progression to end-stage renal disease in AAV patients were analyzed by single factor and multivariate Cox regression.Results A total of 113 cases were enrolled,among which 46 cases(40.7%)were male and 67 cases(59.3%)were female,and 42 patients(37.2%)were over 60 years old.Within six month of initiation of treatment,52 cases(50.0%)achieved renal remission.The survival curve showed that all patients achieved renal remission within 9 months.During the median follow-up period of 13 months(3-77months),a total of 15(20.8%)patients experienced renal recurrence,46(61.8%)AAV patients entered end-stage renal disease,and 2 patients died,all of whom entered end-stage renal disease before death.The survival curve showed that 40% of them entered end-stage renal disease within 1 year.Multivariate Cox regression model showed that long disease duration(OR=1.02,95%CI:1.00～1.04),low e GFR(OR=11.17,95%CI:3.85～32.45)were independent risk factors of progression to end-stage renal disease in patients with AAV renal damage and treatment with cyclophosphamide(OR=0.50,95%CI : 0.27 ～ 0.94)could significantly improve the prognosis of patients with AAV renal damage.Conclusions Long disease duration,poor original renal function are independent risk factors of progression to end-stage renal disease.Hence,physician should strengthen health education to deepen patients’ awareness of AAV.For patients without contraindications,prednisone combined with cyclophosphamide induction remission therapy is recommended to improve clinical prognosis.Part 2 Risk factors for major infections in patients with ANCA associated vasculitis Objective To investigate the clinical characteristics and risk factors of major infections in patients with ANCA associated vasculitis(AAV).Methods One hundred and eighteen consecutive patients newly diagnosed with AAV at the Institute of Nephrology,Tongji hospital affiliated to Hua Zhong University of Science and Technology,from 2012 to 2017,were analyzed retrospectively.Induction therapy include single use of corticosteroids,combination of corticosteroids with cyclophosphamide,and combination of corticosteroids with other immunosuppressive agents.End point was defined as moderate to severe infection which was diagnosed by the clinical and radiological manifestation and microbiological evidences.Moderate and severe infection refers to the infection that needs antibiotics or even hospitalization treatment during the treatment of prednisone and immunosuppressant.According to whether the patients need to be hospitalized for targeted anti-infection treatment,they are divided into moderate infection and severe infection.The infection-related survival curve was drawn to reflect the time when the infection occurred.To identify the clinical baseline variable associated with infection,comparison have been performed respectively between patients with and without infection.Multivariate Logistic regression model was used to determine the independent predictors of infection.Receiver-operating characteristic curve(ROC)was plotted for evaluating the predictive value of lymphocyte on moderate to severe infection.Results 88 infection episodes were found in 63 patients(53.4%)during follow up for median 3 months(1～30 months),of which 54 times(61.4%)occurred within 6 months after treatment,46 times(52.3%)happened within 3 months after treatment.The most common organ of infection was lung(62.5%),followed by urinary tract,skin,digestive tract,long catheterization of the jugular vein.The most common pathogen was bacteria(51.1%),followed by virus(8.0%)and fungus(4.5%).The main CT manifestations of chest include consolidation(50.8%)diffused interstitial pneumonia(25.0%) and multiple nodules(15.8%).Multivariate Logistic regression model showed that lung involvement(OR:4.44,95%CI:1.59～12.41),moderate reduction of lymphocyte in follow-up(OR : 5.69,95%CI : 2.05～15.85)and severe lymphocyte reduction(OR:36.28,95%CI:3.45～381.17)were independent risk factors of secondary infection in patients with AAV.Conclusions Lung involvement,moderate and severe lymphopenia during follow-up were independent risk factors of secondary infection in patients with AAV.Hence,physician should pay more attention to those patients with lung involvement or lymphopenia during the follow-up,and adjust treatment in time to avoid the occurrence of infection.It was shown by ROC curve that the maximum area under the ROC curve(AUC)of lymphocyte about prognosis of severe infection was 0.767(95% CI,0.64～0.89).Based on lymphocyte<0.49×109/L as a predictor of cut-off value of severe infection,the sensitivity was 83.9%,specificity 71.9%,respectively. |
