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Plasma Exchange and Glucocorticoids in Severe ANCA-Associated Vasculitis

Author

N Engl J Med. 2020 Feb 13;382(7):622-631.doi: 10.1056/NEJMoa1803537.

Michael Walsh 1Peter A Merkel 1Chen-Au Peh 1Wladimir M Szpirt 1Xavier Puéchal 1Shouichi Fujimoto 1Carmel M Hawley 1Nader Khalidi 1Oliver Floßmann 1Ron Wald 1Louis P Girard 1Adeera Levin 1Gina Gregorini 1Lorraine Harper 1William F Clark 1Christian Pagnoux 1Ulrich Specks 1Lucy Smyth 1Vladimir Tesar 1Toshiko Ito-Ihara 1Janak Rashme de Zoysa 1Wojciech Szczeklik 1Luis Felipe Flores-Suárez 1Simon Carette 1Loïc Guillevin 1Charles D Pusey 1Alina L Casian 1Biljana Brezina 1Andrea Mazzetti 1Carol A McAlear 1Elizabeth Broadhurst 1Donna Reidlinger 1Samir Mehta 1Natalie Ives 1David R W Jayne 1PEXIVAS Investigators

 

  • PEXIVAS Investigators

Kathy PaizisGiles WaltersMeg JardineCaroline MiltonAbu IbrahamBrian SilvaMichael DesmondVlado PerkovicJadadeesh KurtkotiEswari VilayurAlan CassShaun SummersFiona BrownJessica RyanPeter KerrEuan NobleGrant LuxtonDavid W MudgeCarmel HawleyDavid W JohnsonChen Au PehRandall J FaullDwarakanathan RanganathanLisa JeffsKathy NichollsPeter HughesBruce CooperNeil BoudvilleSharon FordRobyn LanghamDonna ReidlingerAlicia MorrishSunil V BadveElaine PascoePeta-Anne Paul-BrentLaura RobisonAndrea ValksDaniel BlockmansLiesbet HenckaertsBen SprangersRita SuriSoumeya BrachemiWilliam ClarkAmit GargSimon CaretteChristian PagnouxHeather ReichDavid BarthMichael WalshNader KhalidiGerry CoxAndrea Mazzetti1 From the Population Health Research Institute, McMaster University-Hamilton Health Sciences (M.W.), and the Departments of Medicine (M.W., N.K.) and Health Research Methods, Evidence, and Impact (M.W.), McMaster University, and St. Joseph's Healthcare (M.W., N.K., A.M.), Hamilton, ON, the Division of Nephrology and the Li Ka Shing Knowledge Institute, St. Michael's Hospital (R.W.), and the Department of Medicine (R.W.), the Vasculitis Clinic, Department of Rheumatology (C.P., S.C.), and Mount Sinai Hospital, Division of Rheumatology (C.P., S.C.), University of Toronto, Toronto, the Department of Medicine, University of Calgary, Calgary, AB (L.P.G.), the Department of Medicine, University of British Columbia, Vancouver (A.L.), and the Department of Medicine, University of Western Ontario, London (W.F.C.) - all in Canada; the Division of Rheumatology, Departments of Medicine and Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia (P.A.M., C.A.M.); Royal Adelaide Hospital and the University of Adelaide, Adelaide (C.-A.P.), and the Australasian Kidney Trials Network, University of Queensland, Brisbane (C.M.H., D.R.) - all in Australia; Rigshospitalet University Hospital, Department of Nephrology, Copenhagen (W.M.S.); Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Université Paris Descartes, Paris (X.P., L.G.); the Faculty of Medicine, University of Miyazaki, Miyazaki (S.F.), and the Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, and the Clinical and Translational Research Center, University Hospital, Kyoto Prefectural University of Medicine, Kyoto (T.I.-I.) - all in Japan; Royal Berkshire Hospital, Reading (O.F.), the Institute of Clinical Sciences (L.H.) and the Birmingham Clinical Trials Unit, Institute of Applied Health Research (S.M., N.I.), University of Birmingham, Birmingham, the Royal Devon and Exeter NHS Foundation Trust, Exeter (L.S.), the Department of Medicine, Imperial College London (C.D.P.), and Guys and St. Thomas' NHS Foundation Trust (A.L.C.), London, and the Department of Medicine, University of Cambridge (B.B., E.B., D.R.W.J.), and Addenbrooke's Hospital (D.R.W.J.), Cambridge - all in the United Kingdom; Spedali Civili di Brescia, Università di Brescia, Brescia, Italy (G.G.); the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN (U.S.); the Department of Nephrology, General University Hospital, Charles University, Prague, Czech Republic (V.T.); the Renal Service, Waitemata District Health Board, and the Department of Medicine, University of Auckland, Auckland, New Zealand (J.R.Z.); Jagiellonian University Medical College, Krakow, Poland (W.S.); and the Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Mexico City (L.F.F.-S.).

Abstract

Background: More effective and safer treatments are needed for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis.

Methods: We conducted a randomized trial with a 2-by-2 factorial design to evaluate the use of plasma exchange and two regimens of oral glucocorticoids in patients with severe ANCA-associated vasculitis (defined by an estimated glomerular filtration rate of <50 ml per minute per 1.73 m2 of body-surface area or diffuse pulmonary hemorrhage). Patients were randomly assigned to undergo plasma exchange (seven plasma exchanges within 14 days after randomization) or no plasma exchange (control group). Patients were also randomly assigned to follow either a standard-dose regimen or a reduced-dose regimen of oral glucocorticoids. Patients were followed for up to 7 years for the primary composite outcome of death from any cause or end-stage kidney disease (ESKD).

Results: Death from any cause or ESKD occurred in 100 of 352 patients (28.4%) in the plasma-exchange group and in 109 of 352 patients (31.0%) in the control group (hazard ratio, 0.86; 95% confidence interval [CI], 0.65 to 1.13; P = 0.27). The results were similar in subgroup analyses and in analyses of secondary outcomes. We also assessed the noninferiority of a reduced-dose regimen of glucocorticoids to a standard-dose regimen, using a noninferiority margin of 11 percentage points. Death from any cause or ESKD occurred in 92 of 330 patients (27.9%) in the reduced-dose group and in 83 of 325 patients (25.5%) in the standard-dose group (absolute risk difference, 2.3 percentage points; 90% CI, -3.4 to 8.0), which met the criterion for noninferiority. Serious infections at 1 year were less common in the reduced-dose group than in the standard-dose group (incidence rate ratio, 0.69; 95% CI, 0.52 to 0.93), but other secondary outcomes were similar in the two groups.

Conclusions: Among patients with severe ANCA-associated vasculitis, the use of plasma exchange did not reduce the incidence of death or ESKD. A reduced-dose regimen of glucocorticoids was noninferior to a standard-dose regimen with respect to death or ESKD. (Funded by the U.K. National Institute for Health Research and others; PEXIVAS Current Controlled Trials number, ISRCTN07757494; ClinicalTrials.gov number, NCT00987389.).