Yosuke Yamada1, Makoto Harada2, Yuuta Hara2, Ryohei Iwabuchi2, Koji Hashimoto2, Shuhei Yamamoto3, Yuji Kamijo4. 1. Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan. yosukeyama@shinshu-u.ac.jp. 2. Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan. 3. Department of Rehabilitation, Shinshu University Hospital, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan. 4. Department of Nephrology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan. yujibeat@shinshu-u.ac.jp.
Abstract
OBJECTIVE: To assess through systematic review and meta-analysis whether plasma exchange (PE) is associated with prognosis in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) patients. METHODS: A systematic search of PubMed, MEDLINE, Embase, and CENTRAL databases from inception to 17 June 2020 was conducted. Ongoing or unpublished trials were also searched in ClinicalTrials.gov and the World Health Organization trials portal. Randomised controlled trials (RCTs) comparing PE vs. non-PE in AAV patients (microscopic polyangiitis [MPA], granulomatosis with polyangiitis [GPA], or eosinophilic granulomatosis with polyangiitis [EGPA]) were included. The combined risk ratio (RR) was calculated by the random-effects model using the Mantel-Haenszel method. Heterogeneity was measured using the I2 statistic. Primary outcomes were mortality, clinical remission (CR), and adverse events (AEs). RESULTS: Four RCTs comparing PE vs. no PE (N = 827) and 1 RCT comparing PE vs. pulse steroid treatment (N = 137) were included. All participants were MPA or GPA patients (no EGPA patients). PE was not associated with main primary outcomes compared with no PE (mortality RR 0.93 [95% confidence interval {CI} 0.70-1.24], I2 = 0%; CR RR 1.02 [95% CI 0.91-1.15], I2 = 0%; and AE RR 1.10 [95% CI 0.73-1.68], I2 = 37%) or pulse steroid (mortality RR 0.99 [95% CI 0.71-1.37]; CR [the Birmingham Vasculitis Activity score] mean difference - 0.53 [95% CI - 1.40-0.34]; and AE RR 1.05 [95% CI 0.74-1.48]). Focusing on the early treatment phases, PE was associated with a reduction in end-stage renal disease incidence compared with both no PE (PE 1/43 vs. no PE 10/41; RR 0.14 [0.03-0.77] at 3 months) and pulse steroid (PE 11/70 vs. pulse steroid 23/67; RR 0.46 [0.24-0.86] at 3 months). CONCLUSION: We carried out a systematic review and meta-analysis targeting all AAV patients, including MPA, GPA, and EGPA. In AAV patients, performing PE was not associated with the risk of mortality, CR, and AE. No RCT exists evaluating the efficacy of PE for EGPA; hence, this is required in the future. The results may affect the development of guidelines for AAV and may indicate the direction of future clinical research on AAV. TRIAL REGISTRATION: UMIN R000045239 , PROSPERO CRD42020182566 .
OBJECTIVE: To assess through systematic review and meta-analysis whether plasma exchange (PE) is associated with prognosis in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) patients. METHODS: A systematic search of PubMed, MEDLINE, Embase, and CENTRAL databases from inception to 17 June 2020 was conducted. Ongoing or unpublished trials were also searched in ClinicalTrials.gov and the World Health Organization trials portal. Randomised controlled trials (RCTs) comparing PE vs. non-PE in AAVpatients (microscopic polyangiitis [MPA], granulomatosis with polyangiitis [GPA], or eosinophilic granulomatosis with polyangiitis [EGPA]) were included. The combined risk ratio (RR) was calculated by the random-effects model using the Mantel-Haenszel method. Heterogeneity was measured using the I2 statistic. Primary outcomes were mortality, clinical remission (CR), and adverse events (AEs). RESULTS: Four RCTs comparing PE vs. no PE (N = 827) and 1 RCT comparing PE vs. pulse steroid treatment (N = 137) were included. All participants were MPA or GPA patients (no EGPA patients). PE was not associated with main primary outcomes compared with no PE (mortality RR 0.93 [95% confidence interval {CI} 0.70-1.24], I2 = 0%; CR RR 1.02 [95% CI 0.91-1.15], I2 = 0%; and AE RR 1.10 [95% CI 0.73-1.68], I2 = 37%) or pulse steroid (mortality RR 0.99 [95% CI 0.71-1.37]; CR [the Birmingham Vasculitis Activity score] mean difference - 0.53 [95% CI - 1.40-0.34]; and AE RR 1.05 [95% CI 0.74-1.48]). Focusing on the early treatment phases, PE was associated with a reduction in end-stage renal disease incidence compared with both no PE (PE 1/43 vs. no PE 10/41; RR 0.14 [0.03-0.77] at 3 months) and pulse steroid (PE 11/70 vs. pulse steroid 23/67; RR 0.46 [0.24-0.86] at 3 months). CONCLUSION: We carried out a systematic review and meta-analysis targeting all AAVpatients, including MPA, GPA, and EGPA. In AAVpatients, performing PE was not associated with the risk of mortality, CR, and AE. No RCT exists evaluating the efficacy of PE for EGPA; hence, this is required in the future. The results may affect the development of guidelines for AAV and may indicate the direction of future clinical research on AAV. TRIAL REGISTRATION: UMIN R000045239 , PROSPEROCRD42020182566 .
Authors: Jonathan A C Sterne; Jelena Savović; Matthew J Page; Roy G Elbers; Natalie S Blencowe; Isabelle Boutron; Christopher J Cates; Hung-Yuan Cheng; Mark S Corbett; Sandra M Eldridge; Jonathan R Emberson; Miguel A Hernán; Sally Hopewell; Asbjørn Hróbjartsson; Daniela R Junqueira; Peter Jüni; Jamie J Kirkham; Toby Lasserson; Tianjing Li; Alexandra McAleenan; Barnaby C Reeves; Sasha Shepperd; Ian Shrier; Lesley A Stewart; Kate Tilling; Ian R White; Penny F Whiting; Julian P T Higgins Journal: BMJ Date: 2019-08-28
Authors: Michael Walsh; Peter A Merkel; Chen-Au Peh; Wladimir M Szpirt; Xavier Puéchal; Shouichi Fujimoto; Carmel M Hawley; Nader Khalidi; Oliver Floßmann; Ron Wald; Louis P Girard; Adeera Levin; Gina Gregorini; Lorraine Harper; William F Clark; Christian Pagnoux; Ulrich Specks; Lucy Smyth; Vladimir Tesar; Toshiko Ito-Ihara; Janak Rashme de Zoysa; Wojciech Szczeklik; Luis Felipe Flores-Suárez; Simon Carette; Loïc Guillevin; Charles D Pusey; Alina L Casian; Biljana Brezina; Andrea Mazzetti; Carol A McAlear; Elizabeth Broadhurst; Donna Reidlinger; Samir Mehta; Natalie Ives; David R W Jayne Journal: N Engl J Med Date: 2020-02-13 Impact factor: 91.245
Authors: Bertha M Córdova-Sánchez; Juan M Mejía-Vilet; Luis E Morales-Buenrostro; Georgina Loyola-Rodríguez; Norma O Uribe-Uribe; Ricardo Correa-Rotter Journal: Clin Rheumatol Date: 2016-02-06 Impact factor: 2.980
Authors: Richard Watts; Suzanne Lane; Thomas Hanslik; Thomas Hauser; Bernhard Hellmich; Wenche Koldingsnes; Alfred Mahr; Mårten Segelmark; Jan W Cohen-Tervaert; David Scott Journal: Ann Rheum Dis Date: 2006-08-10 Impact factor: 19.103