The effects of plasma exchange and glucocorticoids on early kidney function among patients with ANCA-associated vasculitis in the PEXIVAS trial

Balazs Odler; Regina Riedl; Duvuru Geetha; Wladimir M Szpirt; Carmel Hawley; Lisa Uchida; Zachary S Wallace; Giles Walters; Eri Muso; Vladimir Tesar; Charles D Pusey; Mark A Little; Peter A Merkel; Michael Walsh; David R W Jayne; Andreas Kronbichler; PEXIVAS investigators

doi:10.1016/j.kint.2024.11.029

The effects of plasma exchange and glucocorticoids on early kidney function among patients with ANCA-associated vasculitis in the PEXIVAS trial

Kidney Int. 2024 Dec 19:S0085-2538(24)00911-6. doi: 10.1016/j.kint.2024.11.029. Online ahead of print.

Authors

Balazs Odler¹, Regina Riedl², Duvuru Geetha³, Wladimir M Szpirt⁴, Carmel Hawley⁵, Lisa Uchida⁶, Zachary S Wallace⁷, Giles Walters⁸, Eri Muso⁹, Vladimir Tesar¹⁰, Charles D Pusey¹¹, Mark A Little¹², Peter A Merkel¹³, Michael Walsh¹⁴, David R W Jayne⁶, Andreas Kronbichler¹⁵; PEXIVAS investigators

Affiliations

¹ Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria; Department of Medicine, University of Cambridge, Cambridge, United Kingdom.
² Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria.
³ Division of Nephrology and Division of Rheumatology, Johns Hopkins University, Baltimore, Maryland, USA.
⁴ Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
⁵ The Australasian Kidney Trials Network (AKTN), University of Queensland, Brisbane, Australia.
⁶ Department of Medicine, University of Cambridge, Cambridge, United Kingdom.
⁷ Division of Rheumatology, Allergy, and Immunology; Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Massachusetts, USA.
⁸ Department of Renal Medicine, Canberra Hospital, Canberra, Australian Capital Territory, Australia.
⁹ Department of Nephrology and Dialysis, Medical Research Institute Kitano Hospital, PIIF Tazuke-Kofukai, Osaka, Japan.
¹⁰ Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
¹¹ Department of Immunology and Inflammation, Imperial College London, London, United Kingdom.
¹² Trinity Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Ireland.
¹³ Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
¹⁴ Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada.
¹⁵ Department of Internal Medicine IV, Nephrology and Hypertension, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria. Electronic address: andreas.kronbichler@i-med.ac.at.

PMID: 39708998
DOI: 10.1016/j.kint.2024.11.029

Abstract

Therapeutic plasma exchange (PLEX) is an adjunctive treatment for patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis and kidney involvement. Little is known about the effect of PLEX on early changes in kidney function. This post-hoc analysis of the PEXIVAS trial investigated the effects of PLEX on changes in kidney function within 12 months. PEXIVAS was a randomized controlled trial recruiting 691 patients with ANCA-associated glomerulonephritis, of whom 349 underwent PLEX and 342 received no-PLEX. The primary outcomes of this post hoc study of PEXIVAS were change in estimated glomerular filtration rate (eGFR) from baseline and recovery of kidney function (defined as eGFR increase of 15ml/min/1.73m² or more). Baseline eGFR was 21.7 ± 20.3 and 20.6 ± 18.7 ml/min/1.73m² in the PLEX and no-PLEX groups, respectively. Mean improvements in eGFR at weeks two, four, and eight after initiation of therapy were greater for the PLEX vs. the no-PLEX groups. The greatest significant difference in recovery of kidney function in the PLEX compared to the no-PLEX groups was at week four (relative risk (RR): 1.41; 95% confidence interval:1.09-1.82). Increased eGFR or recovery of kidney function at week four were significantly associated with lower risk for end-stage kidney disease at week 52 (RR: 0.96: 0.95-0.97, and RR: 0.29: 0.16-0.52; respectively). Neither changes in eGFR nor recovery of kidney function differed by reduced- compared to standard-dose glucocorticoid group. Overall, our study indicates that PLEX improves early kidney function in patients with ANCA-associated glomerulonephritis.

Keywords: ANCA; end-stage kidney disease; glomerulonephritis; kidney function; plasma exchange; vasculitis.