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AAV Stopping Immunosuppression Decision — ESENeph MCQ

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ModerateRenal VasculitisAAV Stopping Immunosuppression DecisionESENeph

A 55-year-old man with Wegener granulomatosis (GPA) in complete remission for 5 years asks about stopping all immunosuppression. He is on low-dose Rituximab maintenance (500 mg 6-monthly). PR3-ANCA is positive at low titre. According to KDIGO 2024, what is the recommended approach?

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Correct answer: A — Shared decision-making with long-term relapse monitoring

KDIGO 2024 recommends maintenance therapy for 18 months to 4 years. After this period, the decision to stop requires weighing relapse risk factors (PR3-ANCA positivity, GPA phenotype, prior relapse) against ongoing immunosuppression risks (infection, malignancy). Five years of maintenance is beyond the recommended minimum. Stopping is reasonable but the patient must understand: GPA relapse can occur years after treatment cessation; ongoing clinical and ANCA monitoring is essential; and prompt medical attention for new symptoms is critical. The competing options do not fit the renal phenotype, temporal relationship, treatment threshold or safety constraint described. Management still requires confirmation of current medicines, renal trajectory and relevant contraindications, followed by timely biochemical and clinical reassessment. Escalate urgently if life-threatening electrolyte disturbance, respiratory compromise, shock, neurological deterioration or a dialysis indication develops.

Reference: KDIGO 2024 – ANCA-Associated Vasculitis Guideline: https://kdigo.org/guidelines/gd/