CHICAGO – Plasma exchange remains a reasonable treatment option for certain patients with refractory antineutrophil cytoplasmic antibody–associated vasculitis, according to Dr. Phillip Seo.
For example, in patients with antineutrophil cytoplasmic antibody (ANCA)–associated glomerulonephritis who present with renal failure, this “more traditional therapy that we don't think about much anymore” can delay progression to dialysis and can buy time for patients awaiting renal transplant, Dr. Seo said at the symposium.
Dr. Seo, codirector of the vasculitis center at Johns Hopkins University, Baltimore, presented a case involving a 64-year-old woman diagnosed with pauci-immune glomerulonephritis consistent with ANCA-associated vasculitis (AAV). She was treated with standard high-dose prednisone and cyclophosphamide, but she returned to the emergency department 2 weeks later with dyspnea and was found to have pulmonary hemorrhage.
In patients like this, it is reasonable to consider plasma exchange, he said.
In a randomized trial comparing plasma exchange and methylprednisolone as additional therapy for ANCA-associated glomerulonephritis (the Randomized Trial of Plasma Exchange Versus Methylprednisolone as Additional Therapy for ANCA-Associated Glomerulonephritis or MEPEX), patients randomized to receive seven courses of plasma exchange had significantly better renal survival at 3 months than did those who received methylprednisolone (81% vs. 61% of surviving patients in the groups, respectively, were dialysis independent at 3 months), Dr. Seo said, noting that this effect persisted for the duration of the 12-month observation period.
The problem – and the main reason that plasma exchange has fallen by the wayside as a treatment option for these patients – is that long-term survival did not differ between the groups, he said.
While it is “very reasonable to consider plasma exchange as a standard treatment regimen” because it can potentially allow for a year off hemodialysis, or a year during which a patient can be prepared for renal transplant, patients don't survive any longer, thus it is also reasonable to not offer plasma exchange, he said. “For those of you who don't have access to plasma exchange on a routine basis at your hospital, I think you should still sleep well at night.”
That's not to say the treatment won't regain favor for broader use, he added.
A study now underway – the Plasma Exchange and Glucocorticoids for Treatment of ANCA-Associated Vasculitis (PEXIVAS) trial – is evaluating whether plasma exchange is beneficial in patients with AAV with milder forms of glomerulonephritis, as well as in those with pulmonary capillaritis and hemorrhage.
Dr. Seo disclosed that he is a consultant for Genentech.