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Vimal Derebail, MD

After a review of the PEXIVAS trial, a large randomized clinical trial involving patients with ANCA vasculitis, Vimal K. Derebail, M.D., M.P.H., associate professor of medicine in the division of nephrology and hypertension, and Ronald J. Falk, M.D, chair of the UNC Department of Medicine, have published their interpretation of these findings for patients with severe ANCA vasculitis and ANCA-induced pulmonary hemorrhage.

In the New England Journal of Medicine, the authors report “plasma exchange has been a mainstay of induction therapy for patients with antineutrophil cyto-plasmic antibody (ANCA) vasculitis, who have rapidly progressive glomerulonephritis or diffuse alveolar hemorrhage,” and that “clinical data, in vitro data, and data from studies in animals have shown that ANCAs are pathogenic,” and plasma exchange should “theoretically diminish vascular injury and end-organ damage, and hasten resolution of disease.” The PEXIVAS study found that adding plasma exchange to current standard of care provided no added benefit on the combined outcome of death and end-stage kidney disease.

Dr. Ron Falk
Ron Falk, MD

They acknowledge the trial provides useful insights into induction therapy for ANCA vasculitis. The PEXIVAS findings indicate that plasma exchange should not be used routinely in patients with ANCA vasculitis who have severe kidney dysfunction and indicate less glucocorticoid can be used for treatment of this disease. However, due to some limitations in the study, they suggest plasma exchange may still benefit selected subgroups of patients including those who do not have extensive pre-existing scarring. In the end, they suggest plasma exchange remain part of the induction regimen for patients with ANCA-induced pulmonary hemorrhage until a study specifically designed to evaluate efficacy in patients with pulmonary hemorrhage has been performed.