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Dr. Kronbichler:
This is CME on ReachMD, and I'm Dr. Andreas Kronbichler. Here with me today is Dr. Silke Brix.
So, Silke, what is the diagnostic approach that providers should follow in patients with suspected ANCA-associated vasculitis?
Dr. Brix:
Hi, and thank you, Andreas, for that question. So, yeah, to not miss, and how do we rapidly and accurately diagnose ANCA vasculitis? I think when we look at the different organ manifestations here, for example, say, how do you rapidly and accurately diagnose ANCA-GN when you have a suspicion of vasculitis on the kidney?
That's where we straightforward have a KDIGO guideline that I have a slide for that that nicely shows us how you go along a flow chart to see that you actually not miss a timely biopsy to confirm. And when you weigh up biopsy, yes/no, I do tend to say try to biopsy, really try to minimize the contraindication, remove the contraindication for biopsy, and actually get a biopsy.
And so on the side of and what speaks for doing a biopsy if you don't have a contraindication, actually then just go ahead and do one and confirm. If you're having a patient that isn't like highly MPO/PR3 positive but borderline or even negative, then do a biopsy. If there's a suspicion you have a differential diagnosis or there's an insidious grumbling disease, whenever you're not 100% sure, definitely go ahead and do a biopsy before you start treatment. And the only reason to actually start treatment without a biopsy is, yeah, you do have a contraindication here, or you think this is an organ-/life-threatening disease. I’m having my patient potentially coming to harm by delaying treatment start. That’s when you start treatment without a biopsy. But then, soon after, you actually try to biopsy.
If you're an expert center that does this regularly, if you have a low suspicion of a secondary vasculitis, or if there is a contraindication, then you start treatment. But then you try to remove the contraindication to get actually a biopsy to confirm.
So, and I think this is for ANCA-GN, because I’ve brought on the next slide, just an example.
We had this recently. It comes very classic across a patient that is mighty organ-involved, is 41, has a PR3 of quite significant level of 55. And you think with hematoproteinuria, that it’s an ANCA-GN, and the biopsy actually then does not confirm a pauci-immune but has some focal endocapillary proliferation and does actually look like an MPGN picture.
And that patient had Q fever, so confirmed on a PET CT. So there is really the confirmation of the diagnosis, and that's why you want to have a timely biopsy.
And then there's the next step, and that's where I am having a big interest in, is that we don't not just use the biopsy for confirmation, but actually we use a biopsy timely to then have prognostication and have an impact on how we predict outcome so that we, in the future at some point, be able to even guide treatment.
So for the ANCA-GN side, I think there’s how do you accurately and timely diagnose? The answer is quite simple. Try to have a very quick biopsy done to confirm the diagnosis. Have some prognostication with it, and then you can go ahead with treatment.
If you have an ANCA-GN, so a renal participation, that's great. It gets a bit less straightforward when it's a more insidious disease process, and you start having nonrenal disease. But this is where we perhaps could have a quick discussion between you and me about?
Dr. Kronbichler:
Yeah, I think that's a very, very straightforward decision. I think if you have not a multi-organ involvement and you're not sure about the diagnosis, I think biopsy is needed. If we collect a lot of items on the BVAS, for instance, I think we can also go without a biopsy. And then, if the patient is proven to be refractory or so, you always need to consider potential differential diagnosis.
But as you mentioned, I think it's much more important nowadays to think about the prognostic relevance of a biopsy, and so I think a kidney biopsy is a safe procedure. We know that, especially in experienced hands, and it should be performed.
Dr. Brix:
But that was actually already a nice summary because, yeah, I just want to add in that I sometimes feel, okay, the case is clear enough, let’s go without a biopsy. And I think actually having ourselves, rather, reminded that the biopsy is a crucial part in diagnosing and prognostication. You get surprised what you sometimes see in a biopsy, so the biopsy confirmation is actually, it’s very important. Yeah.
Dr. Kronbichler:
So that's our time. Thank you for listening.
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