Factors associated with major infections in patients with granulomatosis with polyangiitis and systemic lupus erythematosus treated for deep organ involvement.

This study is an audit and a comparison of major infective complications in patients with granulomatosis with polyangiitis (GPA) and systemic lupus erythematosis (SLE). Data were collected on consecutive patients attending a single treatment approach, multidisciplinary vasculitis centre who met diagnostic criteria for GPA and SLE from 01/01/2006 to 30/06/2006. Immunosuppressive treatment is used in this clinic with guidelines targeting avoidance of neutropenia. For each patient, documentation was made of disease presentation, organ involvement and therapy used. A history of major infections requiring hospital admission and intravenous antimicrobials pre- and post-diagnosis was recorded. Patients with GPA received a higher cumulative dose of cyclophosphamide, had a higher median age, shorter period of follow-up and had lower mean and nadir absolute lymphocyte counts and nadir neutrophil counts. GPA patients had more major infections per patient years (P = 0.0027) and respiratory tract infections (P = 0.0031) per patient years. Relative risk (RR) of major infection was significantly increased with methylprednisolone, RR 11.1 (P = <0.0001), cyclophosphamide, RR 2.0 (P = 0.0246) and the intensive phase of treatment, RR 13.3 (P = <0.0001). Marked lymphopenia was common in both groups during follow-up and was associated with an increased risk of major infection (P = 0.0020). Major infections, in particular respiratory tract infections, are more common in those treated for GPA than SLE. This may be due to a combination of factors including greater doses and duration of methyprednisolone and cyclophosphamide. We recommend treatment strategies that aim not only to avoid neutropenia but that also identify lymphopenia as a risk factor for major infection.

Predictive value of myocardial and coronary imaging in the long-term outcome of potential renal transplant recipients.

BACKGROUND: Coronary artery disease is a major cause of morbidity and mortality in renal transplant recipients, but there is no agreed screening protocol. The value of myocardial perfusion imaging (MPI) and coronary angiography (CA) in predicting future cardiovascular events and mortality in unselected dialysis patients was studied. METHODS: Forty seven patients (mean age 51±14 years, 37 males), underwent both CA and MPI as part of pre-renal transplant assessment between 1995 and 1999. Follow-up period was 75±132 (range 3 to 143) months. RESULTS: Twenty-two (46.8%) patients had >50% stenosis of at least one major coronary artery (CAD), only 10 patients had abnormal MPI. Positive CA was found in all patients with angina and in 80% of diabetics. During follow-up 18 (38.3%) patients received a transplant and 28 (59.6%) patients died, of which 16 were proven or suspected cardiac deaths. Survival was significantly longer in patients with negative MPI or CA (92 and 96 versus 29 and 54 months for positive studies, respectively). CA had PPV of 95.7% and NPV of 54.2% for predicting the combined outcome of death and cardiovascular events whereas for MPI and MUGA, PPVs were 90.9% and 73.3% and NPVs 37.8% and 30%, respectively. CONCLUSIONS: Although MPI had a high specificity for CAD detection, its sensitivity appears limited in dialysis patients. The study suggests that those with angina and/or diabetes should undergo CA because of the high incidence of CAD in these groups, but MPI was at least as important as CA in overall mortality prediction over a long follow-up.