Session Type: Poster Session (Monday)
Session Time: 9:00AM-11:00AM
Background/Purpose: Induction therapy for severe ANCA-associated vasculitides (AAVs) is based on the combination of glucocorticoids and cyclophosphamide (CYC) or rituximab (RTX). For patients with severe acute renal impairment, use of RTX alone has not been evaluated in randomized–controlled trials and CYC is usually given in this situation. The additional benefit of plasma exchanges (PEs) is controversial. We compared the efficacies of glucocorticoid and RTX or CYC induction therapy for severe renal AAV flares and evaluated the potential benefit of PE adjunction to manage those flares.
Methods: This retrospective, multicenter study included patients with severe renal flares of granulomatosis with polyangiitis, microscopic polyangiitis or pauci-immune renal-limited vasculitis. The severity of renal impairment was defined as serum creatinine ≥350 μmol/L and/or an estimated glomerular filtration rate ≤15 mL/min/1.73 m2. The primary endpoint was AAV remission at month (M) 3 and M6, and being dialysis-free at M3, M6 and M12. A propensity score and a double robust adjustment were used to compare groups.
Results: Between 2005 and 2017, 173 AAV renal flares occurred in the 161 patients included: 65 (40%) women and 96 (60%) men; mean (±SD) age at the time of the flare was 63 ± 13.1 years. Twenty-nine (17%) flares were treated with RTX and 144 (83%) with CYC. Remission rates did not differ between RTX- and CYC-treated groups, respectively, at M3 (93% vs 94%) and M6 (100% vs 92%). Although more RTX- than CYC-treated patients were dialysis-free at M12 (respectively: 91% vs 69%; odds ratio (OR) 4.59 [95% CI 1.02–20.6]), the difference was not significant after adjustment. At M12, 10 patients—all treated with CYC—had died.
Because of too few RTX-treated flares, PE efficacy was evaluated only for CYC-treated patients. Among 144 CYC-treated flares, 81 (56%) also had PEs. M3 and M6 remission rates were comparable for the weighted CYC groups treated with or without PEs, respectively, at M3 (94% vs 95%) and M6 (92% vs 91%).The dialysis-free survival rates were significantly higher for CYC- and PE-treated patients vs no PE, respectively, in weighted groups (74% vs 65%; OR 2.91 [95% CI 1.11–7.62] at M6 and 73.2% vs 62.3%; OR 3.05 [95% CI 1.13–8.21] at M12). Significance was confirmed after double robust adjustment at M6 (OR 6.91 [95% CI 1.24–38.6]) but not at M12 (OR 5.37 [95% CI 0.90–32.1]).
Conclusion: According to the results of this retrospective study, RTX was apparently equivalent to CYC as induction therapy for patients with severe AAV renal flares. PE adjunction to CYC was associated with higher dialysis-free rates at M6. Despite the use of a propensity score, we were not able to overcome all the biases and these results need to be confirmed by prospective controlled trials. Subgroup analyses may be required to better identify the place of each treatment for AAV patients with severe renal involvement.
To cite this abstract in AMA style:Morel P, Karras A, Porcher R, Belenfant X, Audard V, Rafat C, Hanouna G, Beaudreuil S, Vilain C, Hummel A, Terrier B, Pillebout E, Groh M, Jouenne R, Dhote R, Fain O, Ponsoye M, Noel N, Limal N, Guillevin L, Mouthon L, Régent A. Management of Severe Renal Disease in Anti-Neutrophil-Cytoplasmic-Antibodies Associated Vasculitis: Role of Rituximab and Plasma Exchange? [abstract]. Arthritis Rheumatol. 2019; 71 (suppl 10). https://acrabstracts.org/abstract/management-of-severe-renal-disease-in-anti-neutrophil-cytoplasmic-antibodies-associated-vasculitis-role-of-rituximab-and-plasma-exchange/. Accessed June 3, 2020.
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