BACKGROUND: The use of plasma exchange (PE) for induction treatment of anti-neutrophil cytoplasm autoantibody (ANCA)-associated vasculitis (AAV), including Wegener's granulomatosis (WG), is still controversial. The use of PE in AAV is not commonly accepted in patients with a plasma creatinine <500 μmol/L (5.7 mg/dL) despite experimental support for involvement of ANCA in the pathogenesis of vasculitis. METHODS: In a single-centre study from a tertiary referral centre, 32 patients with ANCA-positive WG were treated with standard immunosuppressive therapy, prednisolone and cyclophosphamide (CYC). In addition, they were randomized to treatment with or without initial PE. After 3 months, they were further randomized in a Latin square design to continue CYC or to change to cyclosporine A (CyA) for 9 months. The renal follow-up was at least 5 years. RESULTS:Renal survival after 1, 3 and 12 months, and 5 years was significantly better in the PE groups. For all groups, the kidney/patient survival was 87.5%/93.7% at 1 year and 72%/56% at 5 years. All patients who were on dialysis when recruited were dialysis dependent 5 years later. There was no difference in morbidity or mortality between PE and control groups. Multivariate analysis demonstrated that PE improved renal survival (P < 0.01) at initial plasma creatinine levels >250 µmol/L (2.85 mg/dL). Change from CYC to CyA did not influence rate of relapses or time to relapse. CONCLUSIONS: PE is recommended for induction therapy in WG patients at creatinine levels >250 µmol/L (2.85 mg/dL), whereas previous randomized studies have limited PE to patients with creatinine >500 µmol/L (5.65 mg/dL).
RCT Entities:
BACKGROUND: The use of plasma exchange (PE) for induction treatment of anti-neutrophil cytoplasm autoantibody (ANCA)-associated vasculitis (AAV), including Wegener's granulomatosis (WG), is still controversial. The use of PE in AAV is not commonly accepted in patients with a plasma creatinine <500 μmol/L (5.7 mg/dL) despite experimental support for involvement of ANCA in the pathogenesis of vasculitis. METHODS: In a single-centre study from a tertiary referral centre, 32 patients with ANCA-positive WG were treated with standard immunosuppressive therapy, prednisolone and cyclophosphamide (CYC). In addition, they were randomized to treatment with or without initial PE. After 3 months, they were further randomized in a Latin square design to continue CYC or to change to cyclosporine A (CyA) for 9 months. The renal follow-up was at least 5 years. RESULTS: Renal survival after 1, 3 and 12 months, and 5 years was significantly better in the PE groups. For all groups, the kidney/patient survival was 87.5%/93.7% at 1 year and 72%/56% at 5 years. All patients who were on dialysis when recruited were dialysis dependent 5 years later. There was no difference in morbidity or mortality between PE and control groups. Multivariate analysis demonstrated that PE improved renal survival (P < 0.01) at initial plasma creatinine levels >250 µmol/L (2.85 mg/dL). Change from CYC to CyA did not influence rate of relapses or time to relapse. CONCLUSIONS: PE is recommended for induction therapy in WG patients at creatinine levels >250 µmol/L (2.85 mg/dL), whereas previous randomized studies have limited PE to patients with creatinine >500 µmol/L (5.65 mg/dL).
Authors: Michael Walsh; Fausta Catapano; Wladimir Szpirt; Kristian Thorlund; Annette Bruchfeld; Loic Guillevin; Marion Haubitz; Peter A Merkel; Chen Au Peh; Charles Pusey; David Jayne Journal: Am J Kidney Dis Date: 2010-12-30 Impact factor: 8.860
Authors: Ying Hong; Despina Eleftheriou; Abdullah A K Hussain; Fiona E Price-Kuehne; Caroline O Savage; David Jayne; Mark A Little; Alan D Salama; Nigel J Klein; Paul A Brogan Journal: J Am Soc Nephrol Date: 2011-11-03 Impact factor: 10.121
Authors: Marta Casal Moura; Maria V Irazabal; Alfonso Eirin; Ladan Zand; Sanjeev Sethi; Bijan J Borah; Jeffrey L Winters; James P Moriarty; Rodrigo Cartin-Ceba; Alvise Berti; Misbah Baqir; Gwen E Thompson; Ashima Makol; Kenneth J Warrington; Viengneesee Thao; Ulrich Specks; Fernando C Fervenza Journal: J Am Soc Nephrol Date: 2020-08-21 Impact factor: 10.121