Is There Still a Role of Plasma Exchange in the Current Management of ANCA-Associated Vasculitides?

Abstract

Purpose of Review Plasma exchange (PLEX) is often recommended as an adjunctive therapy for patients with ANCA-associated vasculitis (AAV) in the setting of rapidly progressive glomerulonephritis or diffuse alveolar haemorrhage. Since ANCAs are pathogenic, it seems a reasonable and justified approach to remove them through therapeutic PLEX, as despite advances in immunosuppressive therapy regimens, AAV is associated with significant morbidity and death. However, the association between ANCA levels and mortality or disease activity is uncertain. In addition, any treatment must be judged on the potential risks and benefits of its use. Here, we summarise the current data on PLEX usage in patients with AAV. Recent Findings The largest randomised trial to date the Plasma Exchange and Glucocorticoids in Severe ANCA-Associated Vasculitis (PEXIVAS) study failed to show added benefit for PLEX on the prevention of death or end-stage renal failure (ESRF) for the management of patients with severe AAV. However, there is a possibility that PLEX delays dialysis dependence and ESRF in the early stages of the disease. Regardless of whether this is only for 3 to 12 months, this could be of clinical significance and a substantial improvement in patient’s quality of life. Summary Cost utility analysis and trials including patient-centred outcomes are required to evaluate the use of PLEX. Furthermore, ascertaining those at high risk of developing ESRF could help identify those who may benefit from PLEX the most, and further insights are required in setting of diffuse alveolar haemorrhage.

Efficacy of protein A immunoadsorption and therapeutic plasma exchange in ANCA-associated vasculitis with severe renal involvement: a retrospective study

“…However, compared with the general population, there was still a mortality ratio of 2.6 in AAV patients due to complications of the disease, such as renal failure or serious infection [ 25 ]. International guidelines recommend TPE as adjuvant therapy for patients with AAV and severe organ involvement, while existing research recommendations vary regarding the use of TPE in AAV and its long-term benefits remain controversial [ 26 ]. The largest randomized trial to date the TPE and GC in severe AAV (PEXIVAS) study failed to show added benefit for TPE in the prevention of death or ESRD for the management of patients with severe AAV [ 11 ].…”