The Real World Investigation Of ANCA And Clinical Analyze Of ANCA Associated Vasculitis

Part 1 The real world investigation of ANCA in single-centerBackground: Anti-neutrophil cytoplasmic antibodies(ANCAs)are autoantibodies reacting with cytoplasmic components of neutrophils and monocytes,myeloperoxidase(MPO)and leukocyte proteinase 3(PR3)which are identified as the main antigenic targets.The presence of ANCAs has provided a serological hallmark for certain systemic vasculitis syndromes known as ANCA-associated vasculitis(AAV),which is characterized by necrotizing inflammation of small-to-medium-sized blood vessels.In addition to being a diagnostic marker,in vitro experiments,animal models for MPO-ANCA and clinical studies demonstrated that ANCA is pathogenic.Nevertheless,the pathogenicity of ANCA remains controversial.For PR3-ANCA disease,the animal model has not been as successful with immunization of rodents with either human or murine,PR3 leads to the induction of PR3 antibodies,but not in the development of disease.In addition,some presence of AAV patients proved by biopsy are ANCA-negative by current clinical assays,and serum ANCA persists in some patients with remission.Moreover,seropositive ANCA has also been detected in many other immune diseases,chronic inflammation and some infections,even some healthy individuals possess autoantibodies against MPO and PR3.Therefore,it is a challenge to evaluate the significance of ANCA presence in sera for clinicians.The research aims to review the patients with seropositive PR3/MPO-ANCA,analyze the real epidemiological characteristics and the clinical significance of ANCA positive patients in practice.Method: Patients with seropositive ANCA from January 2011 to December 2017 in XX Hospital were reviewed.The clinical data were retrieved from electronic medical record system(EMRS),which included age,gender,ANCA subtype and the ICD diagnosis.Data were analysed using SPSS software version 23.0(SPSS,Chicago,IL).Categorical variables are expressed as the number and frequency.Furthermore,comparisons were based on the Chi-square test for categorical variables,and P < 0.05 was considered statistically significant.Result: 1.Among the 25008 ANCA tests(M:F = 13177:11831)performed over the 7-year period,2143(M:F = 949:1194)seropositive ANCA results corresponding to 1633 patients(M:F = 734:899)were identified.The positive rate in female was higher than male(?~2 =66.46,P <0.001).Among the 1633 ANCA positive patients,MPO-ANCA accounted for 68.22%(n=1114),while the PR3-ANCA was 31.11%(n=508)and the remainging 0.67%(n=11)patients with both MPO and PR3.2.Patients with ANCA positive results were distributed in almost all medical departments and most commonly admitted by the nephrology division(n = 1088,66.63%);ANCA positive results were detected in patients across all ages and the average age was 52.88(42,66)years old,most patients were older than 46 years old(67.97%),with the peak at 56-65 years old(21.13%).3.The diagnosis outcomes were a wide spectrum of diseases,only 426(26.08%)patients were diagnosed with clinical AAV.The proportion of AAV diagnosed in MPO positive patients was significantly higher than that of PR3 patients(?~2=43.25,P <0.001).Conclusion: 1.Seropositive ANCA patients were distributed across departments and age groups,the older accounted for the most.2.Seropositive ANCA can be found in a wide spectrum of diseases,ANCA positive does not necessarily mean AAV.3.The diagnosis of patients with ANCA positive should be individualized to avoid missed diagnosis and also overtreatment.Part 2 The clinical significance of ?1-Globulin in anti-neutrophil cytoplasmic antibody associated vasculitisBackground: Studies have shown that the level of serum protein components(SPFs)including serum C reactive protein(CRP),fibrinogen and etc are significantly higher in AAV patients with active stage,and those SPFs are associated with disease activity and progression.Serum protein electrophoresis(SPE),which can separate the SPFs into bands with albumin,?1 globulin,?2 globulin,?1 globulin,?2 globulin and ? globulin,and then calculated the component of bands through percentage.Compared with other specific serum markers,the percentage values of each component can more comprehensively reflect the change level of SPFs in serum.SPE detection is mainly used to diagnose serum protein abnormal related diseases,and can reflect the comprehensive inflammatory state of the body under the condition of acute inflammation,malignant tumor,trauma,necrosis and other diseases.Nevertheless,the clinical significance of SPE in AAV was unclear,we aimed to analyze the clinical significance of SPE in AAV retrospectively.Method: The clinical data of 38 AAV patients in our hospital from January 2017 to June 2019 were retrospectively analyzed.The SPFs were evaluated by SPE.Data were analysed using SPSS software version 23.0.Spearman correlation test was applied to determine the correlations between measurements(including categorical variables and non-normal distribution data).The cumulative percentage of renal function was calculated using the Kaplan–Meier method,the log rank test was made to compare difference between groups.The receiver operating characteristic curve was used to examine the prediction performance for renal survival.A P value < 0.05 was considered statistically significant.Result: 1.The SPE tests showed 84.21% AAV patients selected in this cohort had declined albumin level,84.21% had increased ?1 globulin level,63.16% had increased ?2 globulin level,55.26% had increased ?1 globulin level.After treatment and follow up for 3 months,21(55.3%)out of the 38 AAV patients got renal remission while 17(44.7%)didn't.The level of ?1 globulin in patients without renal remission was significantly higher than patients with renal remission(P =0.010).2.Spearman correlation test showed that the levels of ?1-Globulin were positively correlated with Birmingham vasculitis activity score(BVAS)(r = 0.3827,P = 0.0177),initial serum creatinine(r = 0.4641,P = 0.0033),C reactive protein(CRP)(r = 0.616,P < 0.0001),erythrocyte sedimentation rate(r = 0.3859,P = 0.0183),Interleukin-6(r = 0.4688,P = 0.0059)and D-dimer(r = 0.5978,P = 0.0001).3.The patients were divided into high levels of ?1-Globulin group and low levels of ?1-Globulin group based on the average level of ?1-Globulin(7.22%).Patients with high level of ?1 globulin presented higher level of neutrophil count(P =0.001),serum creatinine(P =0.005),D-dimer(P =0.025),ESR(P =0.012),CRP(P = <0.001),IL-6(P =0.010)than patients with low level ?1 globulin,and presented a lower level of hemoglobin(P =0.001)and serum total protein(P =0.032).4.Kaplan-Meier survival analysis showed that cumulative renal survival rate were significantly lower in patients with high levels of ?1-Globulin than patients with low levels of ?1-Globulin(Log rank = 7.782,P =0.005).5.The receiver operating characteristic curve showed that the prediction performance of ?1-Globulin for renal survival(AUC=0.759)is better than BVAS and CRP(AUC=0.639,0.551).Conclusion: 1.AAV patients with elevated serum ?1-Globulin seems to get poorly renal remission.2.?1-Globulin were positively correlated with BVAS,CRP,ESR,IL-6,and might be an index to evaluate the disease activity.3.The level of serum ?1-Globulin is related to renal prognosis of AAV patients.4.The level of serum ?1-Globulin is expected to be a novel markers for assessing AAV activity and predicting prognosis.Part 3 The clinical significance of thromboelastography parameters in ANCA associated vasculitisBackground: Studies demonstrated a hypercoagulable state and a higher incidence of venous thromboembolic events(VTE)in patients with AAV compared to the general population,not only during active AAV,but also when patients are in remission.In clinical practice,the routine parameters used to evaluate coagulation status are prothrombin time(PT),activated partial thromboplastin time(APTT),fibrinogen and D-dimer etc.These indexes can only reflect the coagulation state in initiation or fibrolysis aspect,but not the whole entity of coagulation.Thromboelastography(TEG),a method of detection which has been widely used in clinic,which can reflect the function of platelets,coagulation factors and fibrinolysis in a more comprehensive and dynamic manner throughout the process of whole blood from activating coagulation to the formation of stable clot.TEG was proven beneficial for predicting the risk of haemorrhage and thrombotic events postoperatively,guiding component blood transfusion and postoperative anti-coagulation or anti-platelet therapy.More recently,Lu et al.showed TEG can comprehensively evaluate the blood hypercoagulation status of patients with nephrotic syndrome,and the abnormality of TEG is associated with the incidence of VTE.Li et al.suggested that TEG was associated with disease activity of systemic lupus erythematosus(SLE).However,whether TEG can be used to fully reflect the coagulation status of AAV patients is unclear.The current study aimed to explore the clinical significance of TEG in newly onset patients with AAV retrospectively.Method: The TEG and clinical data of 47 newly onset patients with AAV from January 2016 to November 2019 in our hospital were retrospectively analyzed.Data were analysed using SPSS software version 23.0.Spearman correlation test was applied to determine the correlations between measurements(including categorical variables and non-normal distribution data).The cumulative percentage of renal function was calculated using the Kaplan–Meier method,the log rank test was made to compare difference between groups.The receiver operating characteristic curve was used to examine the prediction performance for renal survival.A P value < 0.05 was considered statistically significant.Result: 1.The TEG tests showed 78.72%(n=37)AAV patients selected in this cohort had declined R level,65.96%(n=31)had increased MA value,53.19%(n=25)had declined K-time and 76.60%(n=36)had increased ?-angle.After treatment and follow up for 3 months,patients without elevated MA exhibited higher frequency of renal remission than those with elevated MA(P =0.001),and patients without declined K-time exhibited higher frequency of renal remission than those with declined K(P =0.001).2.Patients with elevated MA(>70mm)got higher BVAS(P =0.007),platelet count(P =0.031),Scr(P=0.014),Fibrinogen(P<0.001),ESR(P=0.037),TNF-?(P=0.020),CRP(P=0.029)and IL-6(P=0.008)than those without elevated MA(<70mm).Those patients with declined K(<1min)got higher BVAS(P=0.018),platelet count(P=0.002)and fibrinogen(P=0.007)than those without declined K(>1min).3.Spearman correlation test showed a positive correlation was observed between levels of MA with PLT(r=0.6195,P<0.0001)?FBG(r=0.4787,P=0.0007)?ESR(r=0.4088,P=0.0048)? IL-6(r=0.5113,P=0.0006)? BVAS(r=0.317,P=0.0299),and a negative correlation between K-time with PLT(r=-0.3845,P=0.0076)and s Cr(r=-0.3305,P=0.0233).4.Kaplan-Meier survival analysis showed that cumulative renal survival rate were significantly higher in patients without elevated MA than those patients with elevated MA(log rank = 12.327,P<0.001),and were significantly higher in patients without declined K-time than patients with declined K time(log rank = 10.642,P = 0.001).5.ROC analysis showed that the efficacy of MA and K in predicting renal prognosis was second only to serum creatinine,which was superior to BVAS,CRP and ESR.Conclusion: 1.TEG was abnormal in most patients with AAV,indicating that the blood was hypercoagulable.2.MA is positively correlated with BVAS?ESR?IL-6,which can reflect AAV activity.3.TEG parameters(MA and K)are associated with AAV prognosis,and appropriate anticoagulation therapy or antiplatelet therapy may beneficial for the prognosis.