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Treatment Outcomes of Anti-Neutrophil Cytoplasmic Autoantibody-Associated Vasculitis in Patients Over Age 75 Years: A Meta-Analysis

Author

Morris AD1, Elsayed ME2, Ponnusamy A2, Rowbottom A3, Martin F4, Geetha D5, Dhaygude AP2. Am J Nephrol. 2020 Mar 11:1-9. doi: 10.1159/000506532. [Epub ahead of print]

Author Information

1 Renal Medicine, Royal Preston Hospital, Preston, United Kingdom, a.morris@doctors.org.uk.

2 Renal Medicine, Royal Preston Hospital, Preston, United Kingdom.

3 Department of Immunology, Royal Preston Hospital, Preston, United Kingdom.

4 School of Pharmacy and Biomedical Sciences, University of Central Lancashire, Preston, United Kingdom.

5 Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.

Abstract

BACKGROUND: 

The benefits of treating anti-neutrophil cytoplasmic autoantibody-associated vasculitis (AAV) in advancing age remains unclear with most published studies defining elderly as ≥65 years. This study aims to determine outcomes of induction immunosuppression in patients aged ≥75 years.

METHODS: 

A cohort of patients aged ≥75 years with a diagnosis of AAV between 2006 and 2018 was constructed from 2 centres. Follow-up was to 2 years or death. Analysis included multivariable Cox regression to compare mortality and end-stage renal disease (ESRD) based on receipt of induction immunosuppression therapy with either cyclophosphamide or rituximab. A systematic review of outcome studies was subsequently undertaken amongst this patient group through Pubmed, Cochrane and Embase databases from inception until October 16, 2019.

RESULTS: 

Sixty-seven patients were identified. Mean age was 79 ± 2.9 years and 82% (n = 55) received induction immunosuppression. Following systematic review, 4 studies were eligible for inclusion, yielding a combined total of 290 patients inclusive of our cohort. The aggregated 1-year mortality irrespective of treatment was 31% (95% CI 25-36%). Within our cohort, induction immunosuppression therapy was associated with a significantly lower 2-year mortality risk (hazard ratio [HR] 0.29 [95% CI 0.09-0.93]). The pooled HR by meta-analysis confirmed this with a significant risk reduction for death (HR 0.31 [95% CI 0.16-0.57], I2 = 0%). Treated patients had a lower pooled rate of ESRD, but was not statistically significant (HR 0.71 [95% CI 0.15-3.35]).

CONCLUSION: 

This meta-analysis suggests that patients ≥75 years with AAV do benefit from induction immunosuppression with a significant survival benefit. Age alone should not be a limiting factor when considering treatment.