Session Information
Session Type: Abstract Session
Session Time: 1:00PM-2:30PM
Background/Purpose: Mortality is high in patients with diffuse alveolar hemorrhage (DAH) associated with ANCA-associated vasculitis (AAV). In the PEXIVAS study, plasma exchange (PLEX) did not have a significant impact on the occurrence of death and/or end-stage kidney disease. However, less than 9% had severe DAH. In these patients, death was numerically more common in the absence of PLEX, but did not show a statistically significant difference, possibly due to the small number of events. The objective of this study was to evaluate whether PLEX reduces mortality in patients with severe DAH by emulating a target trial.
Methods: We emulated a target trial using observational data from a national multicenter retrospective database including patients with severe AAV-associated DAH. The primary outcome was 30-day mortality after ICU admission. The primary endpoint was analyzed using a Cox model to account for censored data with adjustment for pre-specified confounders. To emulate a clinical trial, we performed inverse probability weighting using a Cox regression model with prespecified variables (age, ANCA, BVAS, creatinine level >300µM, hemoptysis, SAPSII score, invasive mechanical ventilation during the first 7 days after ICU admission, and methylprednisolone pulses).
Results: We included 184 patients from 42 centers. One hundred forty-four (78.3%) patients received PLEX (PLEX group) and 40 (21.7%) patients did not receive PLEX (no-PLEX group).
Baseline characteristics included median age 66 years [53, 75], female sex 51%, granulomatosis with polyangiitis in 49.5% and MPO-ANCA in 53.3%. Severe DAH was characterized by pulmonary infiltrates in 87.7%, hemorrhagic bronchoalveolar lavage in 71.2%, hemoptysis in 69.6%, and a hemoglobin level of 7.5 [6.6, 8.6] g/dL. Baseline characteristics were similar between the two groups except for more severe renal impairment with a higher creatinine level in the PLEX group (357 µmol/L [IQR 217-511] vs. 171 µmol/L [IQR 84-514], p=0.01). Severity of patients at ICU admission and supportive care was similar between the two groups, with a median SAPS II score of 42 [IQR 31-55] and the need for invasive mechanical ventilation (IMV) in 54% of patients. Intravenous cyclophosphamide was used more frequently in the PLEX group (77% vs. 55%, p=0.01).
Eighty-five percent of patients were alive at 30 days and 73% were alive at 6 months. There was no difference in 30-day survival according to the use of PLEX or not in the emulated cohort, with 30-day survival of 85% (95%CI 81-90) in the PLEX group and 88% (95%CI 77-96) in the no-PLEX group (HR 1.23, 95%CI 0.57-3.89).
Conclusion: This large study of severe AAV-associated DAH shows that PLEX are still widely used and that 30-day mortality is 15%. The target trial emulation study showed that the use of PLEX did not affect early mortality in patients with severe AAV-associated DAH.
To cite this abstract in AMA style:
Sanna A, Gendreau S, Desnos C, Titeca-Beauport D, Malherbe J, Reizine F, Nassarmadji K, Guillaume L, Deroux A, Bendiab E, Catano J, Campagne J, Pineton de Chambrun M, Coirier V, Vigneron C, SAMSON M, Neel A, Brilland B, Martellosio J, Desgrouas M, Simon O, SMETS P, Paule R, Faguer S, Giorgiutti S, Deltombe T, Arrive F, Masson I, Quemeneur T, Durel C, de Montmollin E, Perrin F, Lobbes H, Lajoye Q, Mesbah R, Outh R, Lacraz A, Contou D, Parazols F, Garo F, Ducoux G, Yildiz H, Rey I, Queyrel V, Eid R, Arcani R, Puéchal X, Porcher R, de Prost N, Terrier B. Plasma Exchange for Severe Alveolar Hemorrhage in ANCA-Associated Vasculitis: Emulation of a Target Trial [abstract]. Arthritis Rheumatol. 2024; 76 (suppl 9). https://acrabstracts.org/abstract/plasma-exchange-for-severe-alveolar-hemorrhage-in-anca-associated-vasculitis-emulation-of-a-target-trial/. Accessed .« Back to ACR Convergence 2024
ACR Meeting Abstracts - https://acrabstracts.org/abstract/plasma-exchange-for-severe-alveolar-hemorrhage-in-anca-associated-vasculitis-emulation-of-a-target-trial/