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The impact of sex in the clinical presentation and outcomes of patients with anti-neutrophil cytoplasmic antibodies (ANCA) associated vasculitis (AAV) with glomerulonephritis (AAV-GN) has not been studied, particularly in patients with severe kidney involvement at presentation (eGFR<15mL/min/1.73m2).
A retrospective cohort study on MPO- or PR3-ANCA positive patients with AAV (MPA or GPA) and eGFR<15 ml/min/1.73 m2 or ESKD at presentation. Clinical presentation and outcomes (renal recovery, dialysis at presentation, and ESKD) were analyzed according with sex.
We analyzed 166 patients with biopsy proven active AAV-GN and eGFR <15mL/min/1.73m2 at the time of diagnosis: 78 (47%) were females and 88 (53%) were males. Arterial hypertension was more frequently present in males (85.2% vs. 70.5%, p=0.022). Median serum creatinine (SCr) was higher in males when compared with females (5.2 [IQR 4.2-7.4] vs. 3.6 [IQR 2.8-5.1] mg/dL, p<0.001) but there were no differences in eGFR at presentation. There were no differences between groups in age at diagnosis, GPA versus MPA, ANCA specificity, frequency of alveolar hemorrhage, BVAS score, chronicity score or crescentic features on kidney biopsy. Male patients received IV methylprednisolone more frequently (84.1% vs. 69.2%, p=0.023), but other therapies were similar. Most patients who started dialysis within 4 weeks were males (53.4% vs. 30.8%, p=0.003), however the rate of progression to ESKD at 12 months between groups was similar(p=0.186). When analyzing only the 71 patients that started dialysis within 4 weeks, infections at 12 months were more common in females (75.0% vs. 36.2%, p=0.017). The rate of dialysis initiation or progression to ESKD was not different between males (n=%) versus females (n=%) being on dialysis at 12 months . By multivariable logistic regression, factors related with dialysis initiation within 4 weeks in our cohort were SCr (OR1.478, [95%CI1.231-1.776], p<0.001), alveolar hemorrhage (OR2.726, [95%CI 1.099-6.763], p=0.031) and PR3-ANCA (OR3.155, [95%CI 1.485-6.702], p=0.003) adjusted to sex.
In our cohort, male patients presented with higher SCr and dialysis was started within 4 weeks more frequently. However, this did not reflect in different outcomes as kidney recovery, overall dialysis rates, and progression to ESKD in patients with AAV-GN and eGFR<15mL/min/1.73m2 were not different between groups. Female patients who started dialysis within 4 weeks had an increased frequency of infections at 12 months.