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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44; </span></p><p class="elsevierStylePara">Anti-neutrophil cytoplasmic antibodies &#40;ANCA&#41; are antibodies directed against neutrophil granulocytes and monocytes&#46;<span class="elsevierStyleSup">1</span> These ANCA are essential markers and help to classify small-vessel vasculitides&#44; such as Wegener&#8217;s granulomatosis &#40;WG&#41;&#44; microscopic polyangiitis &#40;MP&#41; and renal-limited vasculitides&#44; which are classified as ANCA-associated systemic vasculitides&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">The diagnosis can be confirmed when ANCA are detected&#46; This means that treatment with steroids and immunosuppressants can be started without delay&#46;<span class="elsevierStyleSup">3</span> In contrast to anti-glomerular basement membrane antibody &#40;anti-GBM&#41; disease&#44; these vasculitides are chronic diseases with a high relapse rate which leads to increased morbidity&#47;mortality&#46;<span class="elsevierStyleSup">4</span> Thus&#44; a diagnosis of relapse in a patient with ANCA-associated small-vessel vasculitis with persistently negative ANCA titre at the moment of a possible relapse should be questioned&#44; requiring either histological proof of disease activity or exclusion of other diagnoses&#46;<span class="elsevierStyleSup">5</span> On the other hand&#44; whether persistently positive levels of ANCA or an increase in their levels can predict vasculitis disease activity is more controversial&#46;<span class="elsevierStyleSup">4&#44;5</span></p><p class="elsevierStylePara">We describe here the case of a patient diagnosed with MP with positive ANCA at the time of diagnosis&#46; The patient did not have any relapses for 7 years while the ANCA were negative and then had 2 relapses in the following 4 years with persistently positive ANCA and while under immunosuppressive maintenance therapy&#46;</p><p class="elsevierStylePara">The patient was a 74-year-old male diagnosed with ANCA-positive MP &#40;anti-myeloperoxidase &#91;anti-MPO&#93; antibodies at a titre of 320U&#47;ml&#44; negative anti-PR3 antibodies&#41; in September 1999&#46; He was treated with oral prednisone at 1mg&#47;kg and monthly pulses of 750mg of cyclophosphamide for 6 months&#46; He also had a medical history of tuberculosis in his youth&#59; spondyloarthrosis and osteoporosis&#59; collapse at D10 vertebra as a complication of steroid treatment&#59; chronic hepatitis with positive HBs-Ag&#44; and positive anti-HBe coinciding with the diagnosis of vasculitis&#46; The patient had been asymptomatic for 7 years with stable kidney function &#40;oscillations of serum creatinine with a range of 1&#46;3-1&#46;8mg&#47;dl&#41;&#44; persistently negative ANCA and without immunosuppressive maintenance therapy&#46; From the seventh year following diagnosis of MP&#44; we started to detect positive ANCA &#40;positive anti-MPO&#41;&#46; The follow-up of the evolution of the ANCA&#44; kidney function parameters and the immunosuppressive treatment established is shown in Table 1&#46;</p><p class="elsevierStylePara">A year and an half after detecting the positive ANCA&#44; the patient was admitted for a respiratory infection without pulmonary consolidation which was treated with levofloxacin&#46; During this hospitalisation&#44; plasma creatinine was 1&#46;4mg&#47;dl&#44; proteinuria 0&#46;28g&#47;24h&#44; C-reactive protein 13mg&#47;dl and an ANCA titre that oscillated between 410 and 429U&#47;ml was found&#46;</p><p class="elsevierStylePara">The first relapse of the disease was found two years and 3 months after the ANCA had become positive and while the patient was undergoing immunosuppressive treatment with oral cyclophosphamide at 50mg&#47;day&#46; The patient had anti-MPO at a titre of 367U&#47;ml and the relapse appeared as acute non-oliguric renal failure &#40;creatinine peak at a maximum of 6&#46;6mg&#47;dl&#41;&#44; microscopic haematuria and pulmonary haemorrhage in the right lung &#40;Figure 1&#41; that responded to treatment with 500mg pulses of 6-methylprednisone i&#46;v&#46; &#40;three doses&#41; followed by oral prednisone at 1mg&#47;kg&#47;day and 500g pulses of cyclophosphamide&#46; Two months after this first relapse&#44; the patient was admitted to hospital for another respiratory infection without pulmonary consolidation that responded well to levofloxacin&#46;</p><p class="elsevierStylePara">The second relapse of the disease was detected four years after the reappearance of the ANCA&#46; This was also seen in the deterioration of kidney function &#40;serum creatinine peak at 4&#46;1mg&#47;dl&#41; and microscopic haematuria and with anti-MPO titres of 126U&#47;ml&#46; The patient responded well to treatment with 500mg pulses of 6-methylprednisolone followed by a descending dosage of oral prednisone starting at 1mg&#47;kg&#47;day and treatment with mycophenolate mofetil at a dose of 500mg&#47;day&#46; The patient was asymptomatic three months after this second relapse with a serum creatinine level of 2&#46;7mg&#47;dl&#44; persistent microhaematuria &#40;20-25 red blood cells&#47;field&#41;&#44; a C-reactive protein of 0&#46;7mg&#47;dl and an anti-MPO titre of 13U&#47;ml&#46;</p><p class="elsevierStylePara">Relapses are the main problem of vasculitides given that they cause mortality and morbidity to increase&#58; chronic organ damage &#40;renal failure&#41; and increased cumulative immunosuppressive therapy toxicity&#46;<span class="elsevierStyleSup">4&#44;6</span> Although the value of ANCA is well established in the diagnosis of these diseases&#44; the usefulness of measuring ANCA titres in assessing disease activity is more controversial&#46;<span class="elsevierStyleSup">7</span> Increased anti-PR3 is associated with a relapse in patients with WG&#44; whereas&#44; persistently high anti-MPO in MP is more contentious&#46; Lurati and Spertini analysed the predictive value of ANCA as a relapse marker in a retrospective study that included 36 patients &#40;23 with WG and 13 with MP&#41;&#46; They studied the prognostic potential of an acute increase in the ANCA titre compared to a persistently positive level of ANCA&#58; persistently high ANCA &#40;over 6 months&#41; were not found to be significantly associated with disease relapse in their study&#44; and the predictive value of an acute increase in the ANCA titre was related to the size of the increase&#46;<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara">In our case&#44; the patient had two relapses over a period of 4 years&#44; during which the anti-MPO titres remained persistently high and&#44; furthermore&#44; the patient was undergoing immunosuppressive maintenance therapy&#46; Also&#44; the relapses occurred regardless of the level of anti-MPO detected&#58; although the first relapse occurred with anti-MPO levels above 350U&#47;ml&#44; the anti-MPO levels had been above 400U&#47;ml a few months before at the time of a respiratory infection&#44; and at this point no relapse had been noted&#46; In the second relapse&#44; the anti-MPO level had been similar to the previous month&#8217;s levels &#40;&#60;150U&#47;ml&#41;&#46; Ayada et al also described a similar case to ours with anti-MPO titres that had been persistently positive for 6 years&#46; The anti-MPO levels were not valuable for predicting relapse early&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">While monitoring ANCA in patients with vasculitis may be helpful for the clinician and may be useful to make a decision on whether to start immunosuppressive treatment&#44; the final decision must be based on clinical and histological parameters in addition to other analytical parameters&#46;<span class="elsevierStyleSup">9</span> In our case&#44; considering that the patient had only received induction therapy when the disease was diagnosed&#44; and still did not have symptoms to consider disease activity &#40;stable kidney function without proteinuria&#41;&#44; preventative immunosuppressive therapy was started when the ANCA reappeared 7 years after the diagnosis and the patient had the first relapse 2 years after starting this treatment&#46;</p><p class="elsevierStylePara">Activation of T-cells&#44; genetic and exogenous causes and infections have been included among the factors associated with relapse&#46; In our case&#44; the patient had been admitted to hospital for a respiratory infection with a maximum peak of anti-MPO within normal levels&#44; although the vasculitis activity was seen seven months later&#46;</p><p class="elsevierStylePara">Furthermore&#44; the reason for preventing relapses is to avoid chronic organ damage&#46; In our case&#44; it can be seen that after the relapse&#44; a progressive worsening of kidney function along with an increased proteinuria was noted&#46;</p><p class="elsevierStylePara">To conclude&#44; persistently positive anti-MPO in patients with MP may not be very useful for predicting relapse&#44; even more so if the patients are undergoing immunosuppressive maintenance therapy&#44; although clinical monitoring must be even stricter in patients with persistently positive anti-MPO titres&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10818&#95;108&#95;17660&#95;en&#95;t110818&#46;jpg" class="elsevierStyleCrossRefs"><img src="10818_108_17660_en_t110818.jpg" alt="Evolution of ANCA titre&#44; kidney function parameters&#44; immunosuppressive treatment and relapses"></img></a></p><p class="elsevierStylePara">Table 1&#46; Evolution of ANCA titre&#44; kidney function parameters&#44; immunosuppressive treatment and relapses</p><p class="elsevierStylePara"><a href="grande&#47;10818&#95;108&#95;17661&#95;en&#95;fa&#95;10818&#46;jpg" class="elsevierStyleCrossRefs"><img src="10818_108_17661_en_fa_10818.jpg" alt="Pulmonary haemorrhage in the right hemithorax &#40;A&#41; before treatment and &#40;B&#41; after receiving immunosuppressive treatment&#46;"></img></a></p><p class="elsevierStylePara">Figure 1a&#46; Pulmonary haemorrhage in the right hemithorax &#40;A&#41; before treatment and &#40;B&#41; after receiving immunosuppressive treatment&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10818&#95;108&#95;17662&#95;en&#95;f1b&#95;10818&#46;jpg" class="elsevierStyleCrossRefs"><img src="10818_108_17662_en_f1b_10818.jpg" alt="Pulmonary haemorrhage in the right hemithorax &#40;A&#41; before treatment and &#40;B&#41; after receiving immunosuppressive treatment&#46;"></img></a></p><p class="elsevierStylePara">Figure 1b&#46; Pulmonary haemorrhage in the right hemithorax &#40;A&#41; before treatment and &#40;B&#41; after receiving immunosuppressive treatment&#46;</p>"
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Relapses in patient with microscopic polyangiitis with persistently positive antimyeloperoxidase for 4 years using maintenance immunosuppressants
Recaídas en paciente con poliangeitis microscópica con anti-mpo persistentemente positivo durante 4 años y con inmunosupresores de mantenimiento
MANUEL HERASa, M.. Herasb, MARIA JOSE FERNANDEZ-REYESa, M.J.. Fernández-Reyesb, ROSA SANCHEZa, R.. Sánchezb, HENAR MUÑOZc, H.. Muñozd, MARIA JOSE JIMENEZc, M.J.. Jiménezd, ALVARO MOLINAa, A.. Molinab
a Servicio de Nefrología, Hospital General de Segovia, Spain,
b Servicio de Nefrología, Hospital General de Segovia,
c Servicio de Análisis Clínicos, Hospital General de Segovia, Spain,
d Servicio de Análisis Clínicos, Hospital General de Segovia,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44; </span></p><p class="elsevierStylePara">Anti-neutrophil cytoplasmic antibodies &#40;ANCA&#41; are antibodies directed against neutrophil granulocytes and monocytes&#46;<span class="elsevierStyleSup">1</span> These ANCA are essential markers and help to classify small-vessel vasculitides&#44; such as Wegener&#8217;s granulomatosis &#40;WG&#41;&#44; microscopic polyangiitis &#40;MP&#41; and renal-limited vasculitides&#44; which are classified as ANCA-associated systemic vasculitides&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">The diagnosis can be confirmed when ANCA are detected&#46; This means that treatment with steroids and immunosuppressants can be started without delay&#46;<span class="elsevierStyleSup">3</span> In contrast to anti-glomerular basement membrane antibody &#40;anti-GBM&#41; disease&#44; these vasculitides are chronic diseases with a high relapse rate which leads to increased morbidity&#47;mortality&#46;<span class="elsevierStyleSup">4</span> Thus&#44; a diagnosis of relapse in a patient with ANCA-associated small-vessel vasculitis with persistently negative ANCA titre at the moment of a possible relapse should be questioned&#44; requiring either histological proof of disease activity or exclusion of other diagnoses&#46;<span class="elsevierStyleSup">5</span> On the other hand&#44; whether persistently positive levels of ANCA or an increase in their levels can predict vasculitis disease activity is more controversial&#46;<span class="elsevierStyleSup">4&#44;5</span></p><p class="elsevierStylePara">We describe here the case of a patient diagnosed with MP with positive ANCA at the time of diagnosis&#46; The patient did not have any relapses for 7 years while the ANCA were negative and then had 2 relapses in the following 4 years with persistently positive ANCA and while under immunosuppressive maintenance therapy&#46;</p><p class="elsevierStylePara">The patient was a 74-year-old male diagnosed with ANCA-positive MP &#40;anti-myeloperoxidase &#91;anti-MPO&#93; antibodies at a titre of 320U&#47;ml&#44; negative anti-PR3 antibodies&#41; in September 1999&#46; He was treated with oral prednisone at 1mg&#47;kg and monthly pulses of 750mg of cyclophosphamide for 6 months&#46; He also had a medical history of tuberculosis in his youth&#59; spondyloarthrosis and osteoporosis&#59; collapse at D10 vertebra as a complication of steroid treatment&#59; chronic hepatitis with positive HBs-Ag&#44; and positive anti-HBe coinciding with the diagnosis of vasculitis&#46; The patient had been asymptomatic for 7 years with stable kidney function &#40;oscillations of serum creatinine with a range of 1&#46;3-1&#46;8mg&#47;dl&#41;&#44; persistently negative ANCA and without immunosuppressive maintenance therapy&#46; From the seventh year following diagnosis of MP&#44; we started to detect positive ANCA &#40;positive anti-MPO&#41;&#46; The follow-up of the evolution of the ANCA&#44; kidney function parameters and the immunosuppressive treatment established is shown in Table 1&#46;</p><p class="elsevierStylePara">A year and an half after detecting the positive ANCA&#44; the patient was admitted for a respiratory infection without pulmonary consolidation which was treated with levofloxacin&#46; During this hospitalisation&#44; plasma creatinine was 1&#46;4mg&#47;dl&#44; proteinuria 0&#46;28g&#47;24h&#44; C-reactive protein 13mg&#47;dl and an ANCA titre that oscillated between 410 and 429U&#47;ml was found&#46;</p><p class="elsevierStylePara">The first relapse of the disease was found two years and 3 months after the ANCA had become positive and while the patient was undergoing immunosuppressive treatment with oral cyclophosphamide at 50mg&#47;day&#46; The patient had anti-MPO at a titre of 367U&#47;ml and the relapse appeared as acute non-oliguric renal failure &#40;creatinine peak at a maximum of 6&#46;6mg&#47;dl&#41;&#44; microscopic haematuria and pulmonary haemorrhage in the right lung &#40;Figure 1&#41; that responded to treatment with 500mg pulses of 6-methylprednisone i&#46;v&#46; &#40;three doses&#41; followed by oral prednisone at 1mg&#47;kg&#47;day and 500g pulses of cyclophosphamide&#46; Two months after this first relapse&#44; the patient was admitted to hospital for another respiratory infection without pulmonary consolidation that responded well to levofloxacin&#46;</p><p class="elsevierStylePara">The second relapse of the disease was detected four years after the reappearance of the ANCA&#46; This was also seen in the deterioration of kidney function &#40;serum creatinine peak at 4&#46;1mg&#47;dl&#41; and microscopic haematuria and with anti-MPO titres of 126U&#47;ml&#46; The patient responded well to treatment with 500mg pulses of 6-methylprednisolone followed by a descending dosage of oral prednisone starting at 1mg&#47;kg&#47;day and treatment with mycophenolate mofetil at a dose of 500mg&#47;day&#46; The patient was asymptomatic three months after this second relapse with a serum creatinine level of 2&#46;7mg&#47;dl&#44; persistent microhaematuria &#40;20-25 red blood cells&#47;field&#41;&#44; a C-reactive protein of 0&#46;7mg&#47;dl and an anti-MPO titre of 13U&#47;ml&#46;</p><p class="elsevierStylePara">Relapses are the main problem of vasculitides given that they cause mortality and morbidity to increase&#58; chronic organ damage &#40;renal failure&#41; and increased cumulative immunosuppressive therapy toxicity&#46;<span class="elsevierStyleSup">4&#44;6</span> Although the value of ANCA is well established in the diagnosis of these diseases&#44; the usefulness of measuring ANCA titres in assessing disease activity is more controversial&#46;<span class="elsevierStyleSup">7</span> Increased anti-PR3 is associated with a relapse in patients with WG&#44; whereas&#44; persistently high anti-MPO in MP is more contentious&#46; Lurati and Spertini analysed the predictive value of ANCA as a relapse marker in a retrospective study that included 36 patients &#40;23 with WG and 13 with MP&#41;&#46; They studied the prognostic potential of an acute increase in the ANCA titre compared to a persistently positive level of ANCA&#58; persistently high ANCA &#40;over 6 months&#41; were not found to be significantly associated with disease relapse in their study&#44; and the predictive value of an acute increase in the ANCA titre was related to the size of the increase&#46;<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara">In our case&#44; the patient had two relapses over a period of 4 years&#44; during which the anti-MPO titres remained persistently high and&#44; furthermore&#44; the patient was undergoing immunosuppressive maintenance therapy&#46; Also&#44; the relapses occurred regardless of the level of anti-MPO detected&#58; although the first relapse occurred with anti-MPO levels above 350U&#47;ml&#44; the anti-MPO levels had been above 400U&#47;ml a few months before at the time of a respiratory infection&#44; and at this point no relapse had been noted&#46; In the second relapse&#44; the anti-MPO level had been similar to the previous month&#8217;s levels &#40;&#60;150U&#47;ml&#41;&#46; Ayada et al also described a similar case to ours with anti-MPO titres that had been persistently positive for 6 years&#46; The anti-MPO levels were not valuable for predicting relapse early&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">While monitoring ANCA in patients with vasculitis may be helpful for the clinician and may be useful to make a decision on whether to start immunosuppressive treatment&#44; the final decision must be based on clinical and histological parameters in addition to other analytical parameters&#46;<span class="elsevierStyleSup">9</span> In our case&#44; considering that the patient had only received induction therapy when the disease was diagnosed&#44; and still did not have symptoms to consider disease activity &#40;stable kidney function without proteinuria&#41;&#44; preventative immunosuppressive therapy was started when the ANCA reappeared 7 years after the diagnosis and the patient had the first relapse 2 years after starting this treatment&#46;</p><p class="elsevierStylePara">Activation of T-cells&#44; genetic and exogenous causes and infections have been included among the factors associated with relapse&#46; In our case&#44; the patient had been admitted to hospital for a respiratory infection with a maximum peak of anti-MPO within normal levels&#44; although the vasculitis activity was seen seven months later&#46;</p><p class="elsevierStylePara">Furthermore&#44; the reason for preventing relapses is to avoid chronic organ damage&#46; In our case&#44; it can be seen that after the relapse&#44; a progressive worsening of kidney function along with an increased proteinuria was noted&#46;</p><p class="elsevierStylePara">To conclude&#44; persistently positive anti-MPO in patients with MP may not be very useful for predicting relapse&#44; even more so if the patients are undergoing immunosuppressive maintenance therapy&#44; although clinical monitoring must be even stricter in patients with persistently positive anti-MPO titres&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10818&#95;108&#95;17660&#95;en&#95;t110818&#46;jpg" class="elsevierStyleCrossRefs"><img src="10818_108_17660_en_t110818.jpg" alt="Evolution of ANCA titre&#44; kidney function parameters&#44; immunosuppressive treatment and relapses"></img></a></p><p class="elsevierStylePara">Table 1&#46; Evolution of ANCA titre&#44; kidney function parameters&#44; immunosuppressive treatment and relapses</p><p class="elsevierStylePara"><a href="grande&#47;10818&#95;108&#95;17661&#95;en&#95;fa&#95;10818&#46;jpg" class="elsevierStyleCrossRefs"><img src="10818_108_17661_en_fa_10818.jpg" alt="Pulmonary haemorrhage in the right hemithorax &#40;A&#41; before treatment and &#40;B&#41; after receiving immunosuppressive treatment&#46;"></img></a></p><p class="elsevierStylePara">Figure 1a&#46; Pulmonary haemorrhage in the right hemithorax &#40;A&#41; before treatment and &#40;B&#41; after receiving immunosuppressive treatment&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10818&#95;108&#95;17662&#95;en&#95;f1b&#95;10818&#46;jpg" class="elsevierStyleCrossRefs"><img src="10818_108_17662_en_f1b_10818.jpg" alt="Pulmonary haemorrhage in the right hemithorax &#40;A&#41; before treatment and &#40;B&#41; after receiving immunosuppressive treatment&#46;"></img></a></p><p class="elsevierStylePara">Figure 1b&#46; Pulmonary haemorrhage in the right hemithorax &#40;A&#41; before treatment and &#40;B&#41; after receiving immunosuppressive treatment&#46;</p>"
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                  "referenciaCompleta" => "Ayada M, Matsuo T, Takada T, Suda S, Okado T, Mori Y, et al. Case of immune complex crescentic glomerulonephritis with consistently hihg titers of MPO-ANCA for 6 years. Nippon Jinzo Gakkai Shi 2007;49(5):511-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17695814" target="_blank">[Pubmed]</a>"
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Article information
ISSN: 20132514
Original language: English
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