title: Randomized trial of plasma exchange or high-dosage methylprednisolone as adjunctive therapy for severe renal vasculitis.
abstract: Systemic vasculitis associated with autoantibodies to neutrophil cytoplasmic antigens (ANCA) is the most frequent cause of rapidly progressive glomerulonephritis. Renal failure at presentation carries an increased risk for ESRD and death despite immunosuppressive therapy. This study investigated whether the addition of plasma exchange was more effective than intravenous methylprednisolone in the achievement of renal recovery in those who presented with a serum creatinine >500 micromol/L (5.8 mg/dl). A total of 137 patients with a new diagnosis of ANCA-associated systemic vasculitis confirmed by renal biopsy and serum creatinine >500 micromol/L (5.8 mg/dl) were randomly assigned to receive seven plasma exchanges (n = 70) or 3000 mg of intravenous methylprednisolone (n = 67). Both groups received oral cyclophosphamide and oral prednisolone. The primary end point was dialysis independence at 3 mo. Secondary end points included renal and patient survival at 1 yr and severe adverse event rates. At 3 mo, 33 (49%) of 67 after intravenous methylprednisolone compared with 48 (69%) or 70 after plasma exchange were alive and independent of dialysis (95% confidence interval for the difference 18 to 35%; P = 0.02). As compared with intravenous methylprednisolone, plasma exchange was associated with a reduction in risk for progression to ESRD of 24% (95% confidence interval 6.1 to 41%), from 43 to 19%, at 12 mo. Patient survival and severe adverse event rates at 1 yr were 51 (76%) of 67 and 32 of 67 (48%) in the intravenous methylprednisolone group and 51 (73%) of 70 and 35 of (50%) 70 in the plasma exchange group, respectively. Plasma exchange increased the rate of renal recovery in ANCA-associated systemic vasculitis that presented with renal failure when compared with intravenous methylprednisolone. Patient survival and severe adverse event rates were similar in both groups.
authors.affiliation: Department of Medicine, Addenbrooke's Hospital, Cambridge, UK. dj106@cam.ac.uk
authors.forename: David R W
authors.initials: DR
authors.lastname: Jayne
authors.forename: Gill
authors.initials: G
authors.lastname: Gaskin
authors.forename: Niels
authors.initials: N
authors.lastname: Rasmussen
authors.forename: Daniel
authors.initials: D
authors.lastname: Abramowicz
authors.forename: Franco
authors.initials: F
authors.lastname: Ferrario
authors.forename: Loic
authors.initials: L
authors.lastname: Guillevin
authors.forename: Eduardo
authors.initials: E
authors.lastname: Mirapeix
authors.forename: Caroline O S
authors.initials: CO
authors.lastname: Savage
authors.forename: Renato A
authors.initials: RA
authors.lastname: Sinico
authors.forename: Coen A
authors.initials: CA
authors.lastname: Stegeman
authors.forename: Kerstin W
authors.initials: KW
authors.lastname: Westman
authors.forename: Fokko J
authors.initials: FJ
authors.lastname: van der Woude
authors.forename: Robert A F
authors.initials: RA
authors.lastname: de Lind van Wijngaarden
authors.forename: Charles D
authors.initials: CD
authors.lastname: Pusey
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D007275:Injections, Intravenous; D007668:Kidney / Q000098:blood supply*; D008297:Male; D008775:Methylprednisolone / Q000008:administration & dosage*; D008875:Middle Aged; D010951:Plasma Exchange; D012720:Severity of Illness Index; D014657:Vasculitis / Q000628:therapy*
chemical_list: D000305:Adrenal Cortex Hormones; D008775:Methylprednisolone