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ANCA vasculitis — SCE Rheumatology MCQ

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HardVasculitisANCA vasculitisSCE Rheumatology

A 64-year-old man with PR3-ANCA-positive granulomatosis with polyangiitis and previous biopsy-proven pauci-immune glomerulonephritis completes 6 months of remission-induction treatment. His ENT symptoms have resolved, serum creatinine is stable and there are no new systemic manifestations. However, microscopic haematuria has persisted on serial urinalyses throughout the 6-month period. Which subsequent outcome is this finding most specifically associated with?

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Correct answer: C — Renal relapse of ANCA-associated vasculitis

Persistent microscopic haematuria after otherwise successful remission induction in ANCA-associated glomerulonephritis is an independent predictor of subsequent renal relapse. The urinary abnormality therefore warrants continued renal surveillance, including urine sediment, protein quantification, creatinine and eGFR. PR3-ANCA positivity also increases overall relapse propensity, but the persistent haematuria specifically points towards renal rather than isolated ENT or pulmonary relapse. Persistent proteinuria, more than haematuria, has been associated with death or kidney failure in European trial cohorts. Urothelial malignancy remains an important alternative cause of haematuria, particularly after cyclophosphamide exposure, and may require separate investigation; however, it is not the outcome specifically predicted by persistent haematuria in AAV remission cohorts.

Reference: Benichou N et al. Proteinuria and hematuria after remission induction are associated with outcome in ANCA-associated vasculitis. Kidney International. 2023. https://pubmed.ncbi.nlm.nih.gov/36940799/