Background Treatment of patients with ANCA-associated vasculitis (AAV) and severe renal involvement is not established. We describe outcomes in response to rituximab (RTX) versus cyclophosphamide (CYC) and plasma exchange (PLEX). Methods A retrospective cohort study of MPO- or PR3-ANCA-positive patients with AAV (MPA and GPA) and severe kidney disease (eGFR,30 ml/min per 1.73 m2). Remission, relapse, ESKD and death after remission-induction with CYC or RTX, with or without the use of PLEX, were compared. Results Of 467 patients with active renal involvement, 251 had severe kidney disease. Patients received CYC (n5161) or RTX (n564) for remission-induction, and 51 were also treated with PLEX. Predictors for ESKD and/or death at 18 months were eGFR,15 ml/min per 1.73 m2 at diagnosis (IRR 3.09 [95% CI 1.49 to 6.40], P50.002), renal recovery (IRR 0.27 [95% CI 0.12 to 0.64], P50.003) and renal remission at 6 months (IRR 0.40 [95% CI 0.18 to 0.90], P50.027). RTX was comparable to CYC in remission-induction (BVAS/ WG50) at 6 months (IRR 1.37 [95% CI 0.91 to 2.08], P50.132). Addition of PLEX showed no benefit on remission-induction at 6 months (IRR 0.73 [95% CI 0.44 to 1.22], P50.230), the rate of ESKD and/or death at 18 months (IRR 1.05 [95% CI 0.51 to 2.18], P50.891), progression to ESKD (IRR 1.06 [95% CI 0.50 to 2.25], P50.887), and survival at 24 months (IRR 0.54 [95% CI 0.16 to 1.85], P50.330). Conclusions The apparent benefits and risks of using CYC or RTX for the treatment of patients with AAV and severe kidney disease are balanced. The addition of PLEX to standard remission-induction therapy showed no benefit in our cohort. A randomized controlled trial is the only satisfactory means to evaluate efficacy of remission-induction treatments in AAV with severe renal involvement.

Efficacy of rituximab and plasma exchange in antineutrophil cytoplasmic antibody-associated vasculitis with severe kidney disease / Casal Moura, Marta; Irazabal, Maria V.; Eirin, Alfonso; Zand, Ladan; Sethi, Sanjeev; Borah, Bijan J.; Winters, Jeffrey L.; Moriarty, James P.; Cartin-Ceba, Rodrigo; Berti, Alvise; Baqir, Misbah; Thompson, Gwen E.; Makol, Ashima; Warrington, Kenneth J. K; Thao, Viengneesee; Specks, Ulrich; Fervenza, Fernando C.. - In: JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY. - ISSN 1046-6673. - 31:11(2020), pp. 2688-2704. [10.1681/ASN.2019111197]

Efficacy of rituximab and plasma exchange in antineutrophil cytoplasmic antibody-associated vasculitis with severe kidney disease

Berti, Alvise;
2020-01-01

Abstract

Background Treatment of patients with ANCA-associated vasculitis (AAV) and severe renal involvement is not established. We describe outcomes in response to rituximab (RTX) versus cyclophosphamide (CYC) and plasma exchange (PLEX). Methods A retrospective cohort study of MPO- or PR3-ANCA-positive patients with AAV (MPA and GPA) and severe kidney disease (eGFR,30 ml/min per 1.73 m2). Remission, relapse, ESKD and death after remission-induction with CYC or RTX, with or without the use of PLEX, were compared. Results Of 467 patients with active renal involvement, 251 had severe kidney disease. Patients received CYC (n5161) or RTX (n564) for remission-induction, and 51 were also treated with PLEX. Predictors for ESKD and/or death at 18 months were eGFR,15 ml/min per 1.73 m2 at diagnosis (IRR 3.09 [95% CI 1.49 to 6.40], P50.002), renal recovery (IRR 0.27 [95% CI 0.12 to 0.64], P50.003) and renal remission at 6 months (IRR 0.40 [95% CI 0.18 to 0.90], P50.027). RTX was comparable to CYC in remission-induction (BVAS/ WG50) at 6 months (IRR 1.37 [95% CI 0.91 to 2.08], P50.132). Addition of PLEX showed no benefit on remission-induction at 6 months (IRR 0.73 [95% CI 0.44 to 1.22], P50.230), the rate of ESKD and/or death at 18 months (IRR 1.05 [95% CI 0.51 to 2.18], P50.891), progression to ESKD (IRR 1.06 [95% CI 0.50 to 2.25], P50.887), and survival at 24 months (IRR 0.54 [95% CI 0.16 to 1.85], P50.330). Conclusions The apparent benefits and risks of using CYC or RTX for the treatment of patients with AAV and severe kidney disease are balanced. The addition of PLEX to standard remission-induction therapy showed no benefit in our cohort. A randomized controlled trial is the only satisfactory means to evaluate efficacy of remission-induction treatments in AAV with severe renal involvement.
2020
11
Casal Moura, Marta; Irazabal, Maria V.; Eirin, Alfonso; Zand, Ladan; Sethi, Sanjeev; Borah, Bijan J.; Winters, Jeffrey L.; Moriarty, James P.; Cartin-...espandi
Efficacy of rituximab and plasma exchange in antineutrophil cytoplasmic antibody-associated vasculitis with severe kidney disease / Casal Moura, Marta; Irazabal, Maria V.; Eirin, Alfonso; Zand, Ladan; Sethi, Sanjeev; Borah, Bijan J.; Winters, Jeffrey L.; Moriarty, James P.; Cartin-Ceba, Rodrigo; Berti, Alvise; Baqir, Misbah; Thompson, Gwen E.; Makol, Ashima; Warrington, Kenneth J. K; Thao, Viengneesee; Specks, Ulrich; Fervenza, Fernando C.. - In: JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY. - ISSN 1046-6673. - 31:11(2020), pp. 2688-2704. [10.1681/ASN.2019111197]
File in questo prodotto:
File Dimensione Formato  
Efficacy of Rituximab and Plasma Exchange in Antineutrophil Cytoplasmic Antibody–Associated Vasculitis with Severe Kidney Disease - PMC.pdf

accesso aperto

Tipologia: Post-print referato (Refereed author’s manuscript)
Licenza: Tutti i diritti riservati (All rights reserved)
Dimensione 2.97 MB
Formato Adobe PDF
2.97 MB Adobe PDF Visualizza/Apri
efficacy_of_rituximab_and_plasma_exchange_in.20.pdf

accesso aperto

Tipologia: Versione editoriale (Publisher’s layout)
Licenza: Tutti i diritti riservati (All rights reserved)
Dimensione 789.83 kB
Formato Adobe PDF
789.83 kB Adobe PDF Visualizza/Apri

I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione

Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/11572/417590
Citazioni
  • ???jsp.display-item.citation.pmc??? 27
  • Scopus 51
  • ???jsp.display-item.citation.isi??? 47
  • OpenAlex ND
social impact