Treatment of glomerulonephritis in microscopic polyangiitis and Churg-Strauss syndrome. Indications of plasma exchanges, Meta-analysis of 2 randomized studies on 140 patients, 32 with glomerulonephritis.

ABSTRACT

UNLABELLED Although plasma exchanges (PE) have no added benefit in the treatment of vasculitides of the polyarteritis nodosa (PAN) group with steroids (CS) +/- cyclophosphamide (CY), this has not been demonstrated in patients presenting with glomerulonephritis (GN). We therefore reanalyzed the records of microscopic polyangiitis (MPA) or Churg-Strauss syndrome (CSS) patients presenting with GN. PATIENTS AND METHODS: Patients were included consecutively in 2 randomized trials a) comparing CS vs CS + PE (n = 78) and b) comparing CS + pulse CY +/- PE in PAN and CSS with factors of poor prognosis (n = 62); 9-12 PE/patient were performed. RESULTS: 32 patients, 18 men and 14 women, presented with GN, 28 MPA and 4 CSS, mean age 53.2 +/- 17 years. Clinical/biological manifestations before treatment were comparable in both groups weight loss 84.4%, fever 62.5%, mononeuritis multiplex 62.5%, purpura 28.1%, GI tract involvement 43.8%, arthritis 37.5%, asthma 12.5%, CNS manifestations 9.4%; cardiac involvement 9.4%; mean creatininemia was 303 +/- 286 mumol/l, proteinuria > 0.5 g/l or 1g/d was found in every case, microscopic hematuria in 20/32 patients, leukocyturia in 12/32. Eight out of/16 were ANCA-positive, ELISA detected anti-MPO antibodies in 5 and anti-PR3 in 3. HBV infection was never observed. After 1 year of treatment, creatininemia decreased from 374.4 +/- 352 to 290 +/- 352 mumol/l in the PE group and from 287 +/- 292 to 170 +/- 67 in the non PE group (NS). Six patients of the PE group and 2 of the non-PE group were dialyzed at onset of treatment. Four of the 6 PE patients and 1 of the 2 not treated with PE were off dialysis 1 year later. In addition 1 patient from the PE group developed a flare with renal failure and required chronic dialysis. The 5-year survival was higher in the PE group (4 deaths/19) than in the non PE group (7/13). The survival curve was 74% in the PE group vs 54% in the non-PE group (NS). CONCLUSION: This study confirms that PE have no added benefit in the treatment of GN in MPA and CSS.