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Morris AD, Elsayed ME, Ponnusamy A, Rowbottom A, Martin F, Geetha D, Dhaygude AP: Treatment Outcomes of Anti-Neutrophil Cytoplasmic Autoantibody-Associated Vasculitis in Patients Over Age 75 Years: A Meta-Analysis. American Journal of Nephrology DOI 10.1159/000506532
ANCA-associated vasculitis (AAV) preferentially affects an older population of adults. The use of potent immunosuppressive agents (such as cyclophosphamide [CYC] or rituximab [RTX]) for treatment might expose these older patients to an excess risk of adverse events and impact outcomes in an important way. Morris and colleagues sought to analyze this issue by conducting a retrospective study of an elderly cohort (n = 67) from two centers (UK and USA), and by performing a systematic review and meta-analysis of relevant publications (totaling 290 subjects, including their cohort). The patients analyzed were all aged 75 years or more at diagnosis. All cases were “pure” ANCA-associated disease.
Compared to untreated patients (those not receiving induction therapy) the hazard ratio (HR) for mortality at 2 years of follow-up for the treated patients (those receiving induction therapy; CYC or RTX) was 0.29 (95% CI 0.09–0.33) for the two-center cohort. The systematic review and meta-analysis showed a similar effect of treatment on HR for mortality (HR 0.31; 95% CI 0.16–0.57). However, the rate of ESKD was not significantly reduced by treatment (HR 0.71; 95% CI 0.16–3.35). The analysis may have been underpowered to show such an effect, even if it was present. The impact on mortality was mostly seen in the first 6 months after starting treatment. Serious adverse events (mainly infection) were seen more commonly in the treated populations. Histologic markers of prognosis were not utilized in this study.
These data, although retrospective and observational – thereby subject to bias and confounding by unmeasured variables – support that elderly patients do receive benefits from induction therapy for AAV, primarily better short-term survival, rather than prevention of ESRD (2 years or less of follow-up). Thus, age alone should not be a consideration in treatment decision making. Whether the combination of age, comorbidity, and histologic prognostic indicators can be used in treatment decisions requires further study.
