Clinical And Genetic Studies Of Systemic Vasculitis

PART ONE Clinical analysis and long-term prognosis of 944 patients with ANCA-associated vasculitis in China.Objective:To analyze the clinical prognosis of patients with ANCA-associated vasculitis in a large single-center of Peking Union Medical College Hospital.Methods:The baseline data of patients with ANCA-associated vasculitis hospitalized in Peking Union Medical College Hospital from 2000 to 2019 were retrospectively included.The time of clinical diagnosis of AAV was taken as the starting time of the study.The baseline data of demography,clinical characteristics and immunological indexes were collected and followed up.Death,relapse,end-stage renal disease,severe pulmonary infection and cardiovascular events were taken as the end point of the study.Life table method and Kaplan-Meier curve were used to describe and analyze,and the stratified Kaplan-Meier curve was tested by Log-Rank method.The indicators with statistical significance,Cox univariate regression analysis and clinical indicators that may have statistical significance were further analyzed by Cox multivariate regression analysis.Result:There were 944 AAV patients including 480 MPA,318 GPA and 146 EGPA,female to male was 0.97:1,1.18:1 and 1.75:1,the age of onset was 63(55,71),45(27,56)and 43(27,59)year-old,and the time from onset to diagnosis was 3(2,11),5(2,15)and 18(6,60)months,respectively.Among the organ involvement,the more common clinical manifestations in MPA patients were pulmonary interstitial lesions and kidney involvement;those in GPA patients were lung nodule/cavity,kidney,ENT involvement;those in EGPA patients were lung infiltration and nose/paranasal sinuse involvement.P-ANCA/MPO-ANCA was dominant in MPA and EGPA,and c-ANCA/PR3-ANCA was dominant in GPA.The BVAS scores of MPA,GPA and EGPA were 20(17,25),22(18,28)and 19(14,26),respectively;VDI scores were 3(2,4),4(2,5)and 4(3,6),respectively.The main treatment was glucocorticoid and cyclophosphamide.Pulmonary infection is the most common complication.355 MPA,263GPA and 110 EGPA(728 AAV)patients were followed up,and the follow-up period was 29,43 and 34 months,respectively.Pulmonary infection is the most common complication.(1)During the follow-up period,107 MPA patients(30.1%),39 GPA patients(14.8%)and 10 EGPA patients(9.1%)died,respectively.MPA,GPA and EGPA patients mainly died of pulmonary infection or primary disease activity.The 1-year cumulative survival rates of AAV patients were 89.3%.The cumulative mortality rates of MPA patients at 3 months,6 months and 1 year were 10.6%,13.6%and 16.4%,respectively.The independent risk factors of death in MPA patients included late age of onset(HR=1.037,P<0.001),pulmonary involvement(HR=4.530,P=0.001),renalinsufficiency(HR=1.715,P=0.018),pulmonary infection(HR=2.804,P<0.001).The independent risk factors for death in GPA patients included renal involvement(HR=4.231,P=0.02)and lung infection(HR=2.607,0.004).The risk factors for death of EGPA included BVAS ? 30(?2=6.537,P=0.011),VDI?5(?2=11.115,P=0.001),malignant tumor(?2=9.955,P=0.003)and severe infection(?2=25.337,P<0.001).(2)During the follow-up period,138 MPA patients(45.8%),183 GPA patients(74.4%)and 67 EGPA patients(63.8%)had a relapse.The 1-year relapse-free survival rates of AAV patients were 70.6%.The cumulative recurrence rates of 6 months and 1 year in GPA patients were 20.5%and 36%,respectively.The cumulative recurrence rates of 6 months and 1 year in EGPA patients were 23.8%and 41.8%,respectively.The independent risk factors of recurrence in MPA patients were male(HR=1.565,P=0.015),pulmonary infiltration(HR=1.49,P=0.032),and creatinine 250-499 ?mol/l(HR=1.979,P=0.001).The independent risk factors for recurrence in GPA patients were hemoptysis(HR=1.531,P=0.012).The independent risk factors of recurrence in EGPA patients were pleural effusion(HR=2.598,P=0.005)and pulmonary infection(HR=2.468,P=0.001),while deep venous thrombosis of lower extremity(HR=0.254,P=0.006)was the independent protective factor.(3)During the follow-up period,68 MPA patients,21 GPA patients and 1 EGPA patient developed ESRD.The one-year renal survival rates of AAV patients were 90.1%.The 3-month,6-month and 1-year survival rates of end-stage renal disease in patients with MPA were 12%,12.6%and 14.4%,respectively.The independent risk factors of ESRD in AAV patients included alveolar hemorrhage(HR=2.368,P<0.001),baseline creatinine level(HR=1.003,P<0.001)and high VDI score(HR=1.218,P=0.002),while independent protective factors including ENT involvement(HR=0.4,P=0.013).(4)During the follow-up period,113 MPA(31.8%),29 GPA(10.9%)and 3(2.7%)EGPA patients had severe pulmonary infection.The overall 1-year severe pulmonary infection-free survival rate of AAV patients was 84%.The 3-month,6-month and 1-year survival rates of severe pulmonary infection in MPA patients were 20.2%,23.4%and 25.9%respectively.The 3-month,6-month and 1-year survival rates of severe pulmonary infection in GPA patients were 4.9%,6.3%and 7.6%,respectively.The independent risk factors of secondary severe pulmonary infection in MPA patients included pulmonary involvement(HR=2.775,P=0.018),proteinuria(HR=4.027,P=0.002)and high creatinine level(HR=1.001,P=0.005).The independent risk factors of severe pulmonary infection in GPA patients included alveolar hemorrhage(HR=2.92,P=0.021),renal involvement(HR=9.154,P=0.03).(5)During the follow-up period,cardiovascular events occurred in 42 MPA(11.9%),10 GPA(3.8%)and 9 EGPA patients(8.2%).The 1-year cardiovascular event-free survival rates of AAV patients were 94.40%.The 6-month and 1-year survival rates of cardiovascular events in MPA patients were 8.8%and 9.5%,respectively.The independent risk factors of cardiovascular events in patients with AAV included late age of onset(HR=1.033,P=0.001),high creatinine level(HR=1.001,P<0.001)and severe infection(HR=4.746,P<0.001).Conclusion:1.ANCA-associated vasculitis is a rare systemic necrotizing vasculitis with strong clinical heterogeneity.The mortality and recurrence rate are still high,and secondary pulmonary infection and cardiovascular events are also common during the course of the disease.2.Pulmonary infection is not only the main cause of death in AAV patients,but also an independent predictor of death in MPA and GPA patients.MPA patients have a higher risk of death within 3 months after diagnosis.In addition,the five-factor score has important clinical value in evaluating the prognosis of AAV.3.GPA and EGPA patients have a higher risk compared with MPA.When MPA patients with male,pulmonary infiltration,and creatinine 250-499 umol/1,GPA patients with hemoptysis,EGPA patients with pleural effusion and secondary pulmonary infection,have the risk of recurrence.4.Baseline creatinine level,alveolar hemorrhage and high VDI score were independent risk factors for end-stage renal disease in AAV patients.Severe infection is also an independent risk factor for cardiovascular events secondary to AAV.Therefore,it is necessary to identify and diagnose early,prevent infection and optimize the risk and benefit ratio of glucocorticoid and immunosuppression in order to improve the prognosis of patients.PART TWO Genetic study of patients with Takayasu arteritisObjective:to explore the susceptibility genes of Takayasu arteritis in Chinese Han population,DNA was sequenced by whole exon sequencing(WES)in Takayasu arteritis patients of the outpatient clinic of Peking Union Medical College Hospital(PUMCH)and healthy controls,and the sequencing results were analyzed by genome-wide association study(GWAS)and Burden analysis.Methods:The basic information and peripheral blood samples of 200 TAK patients from the outpatient department of rheumatic immunology department of PUMCH and 1675 gender-matched healthy controls of Novo-zhonghua Database were collected.DNA was extracted and sequenced with high-throughput and high-depth by Illumina platform,and the sequencing results were detected and annotated.The results of mutation detection were analyzed and screened by Advanced analysis,GWAS and Burden analysis to explore the possible susceptibility genes and loci of TAK,which were also analyzed in different clinical subgroup in order to explore the relationship between susceptibility genes or loci and clinical phenotype.Results:1.In this study,GWAS analysis showed that there were 152 significant single nucleotide polymorphisms(SNP)in TAK,which were distributed in 114 genes(P<5×10-7).It was observed that there were significant differences in 8 sites of the known CCHCR1 gene between patients and normal subjects,of which seven loci are located in the same monomorphic type.In addition,the rs130065 and rs130075 loci of CCHCR1 are missense mutations in the highly conserved region of the genome,which may affect the structure or function of proteins.2.The pathway enrichment of significant gene by GWAS showed that AGER and F11R genes were located in the inflammatory response pathway,ACTN2 and F11R in the leukocyte transendothelial migration pathway,and GNG7 in the chemokine signal pathway.3.Burden analysis showed that there were 15 significant genes in TAK(P<0.001),in which NT5E gene was enriched in the inflammatory response pathway.4.The analysis of clinical subgroups showed that the rs3134940 mutation of AGER was more common in TAK patients with pulmonary artery abnormality or pulmonary artery occlusion and pulmonary hypertension(P<0.05).The rs28365980 T allele of F11R is more common in with TAK patients complicated with coronary artery abnormality or wall thickening;The rs28365980 wild-type was more common in TAK patients with pulmonary artery abnormality and left ventricular enlargement(P<0.05).NT5E mutant gene was more common in TAK patients with pulmonary artery occlusion(P<0.05).The rs7247161 heterozygous locus of GNG7 was more common in TAK patients with aortic valve stenosis(P<0.05).The rs130065 mutation of CCHCR1 is more common in TAK patients with pulmonary hypertension and pulmonary artery dilatation,while the rs130075 mutation in patients with cerebral artery occlusion,and the wild-type in patients with renal artery stenosis(P<0.05).Conclusion:1.The unreported genes related to TAK inflammatory response pathway were AGER(rs3134940),F11R(rs28365980),ACTN2(rs1768053),GNG7(rs7247161)and NT5E genes.However,further verification is required.2.The rs3134940 mutation of AGER,the rs130065 mutation of CCHCR1 and the NT5E mutant gene may be associated with TAK patients with pulmonary artery disease,T allele of F11R is associated with coronary artery abnormalities in TAK patients;the rs28365980 wild-type may be associated with TAK patients with pulmonary artery abnormality and left ventricular enlargement.The rs7247161 heterozygous type of GNG7 may be associated with TAK patients with aortic valve stenosis.The rs130075 mutation of CCHCR1 may be related to TAK patients with cerebral artery occlusion,while the wild type may be related to TAK patients with renal artery stenosis.