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A prospective randomized trial of plasma exchange as additive therapy in idiopathic crescentic glomerulonephritis.
Insights
Plasma exchange did not improve outcomes for patients with rapidly progressive glomerulonephritis not requiring dialysis. Standard drug therapy is as effective as adding plasma exchange for these patients.
Area of Science:
- Nephrology
- Immunology
Background:
- Crescentic glomerulonephritis (CGN) is a severe kidney disease.
- Idiopathic rapidly progressive glomerulonephritis (RPGN) requires effective treatment to prevent kidney failure.
Purpose of the Study:
- To compare the efficacy of drug therapy alone versus drug therapy plus plasma exchange in patients with CGN.
- To determine if plasma exchange offers additional benefit in preventing dialysis dependence or improving renal function.
Main Methods:
- A prospective randomized trial involving 32 patients with CGN.
- Patients were assigned to receive either standard drug therapy (methylprednisolone, prednisone, azathioprine) or the same drug therapy plus plasma exchange.
- Randomization was stratified based on dialysis need, oliguria, and sclerosis.
Main Results:
- No significant difference in the ability to discontinue dialysis or the need to initiate dialysis between the two groups.
- Similar serum creatinine levels and trends over 12 months in both the control and plasma exchange groups.
- Higher incidence of pulmonary infections and deaths in the plasma exchange group.
Conclusions:
- Plasma exchange does not provide additional therapeutic benefit for patients with idiopathic RPGN who are not dialysis-dependent at presentation.
- Standard immunosuppressive drug therapy is sufficient for this patient population.
Abstract:
Sixty-three patients with crescentic glomerulonephritis (cellular crescents in greater than 50% of glomeruli) were considered for a prospective randomized trial comparing intravenous methylprednisolone, prednisone, and azathioprine with and without plasma exchange. Of 32 patients who fulfilled the inclusion criteria for this study, 16 were randomly assigned to receive drug therapy (control) and 16 to receive plasma exchange as well. The randomization was stratified for initial need of dialysis, and the presence of oliguria and sclerosis. Renal pathology was similar in the two groups of patients. There was no significant difference in the number of patients initially on dialysis who were able to discontinue it during the study (2/7 control v 3/4 plasma exchange), whereas no control but two plasma exchange-treated patients started dialysis during the study. Serum creatinine at randomization was similar in the two groups: 769 +/- 486 mumol/L (8.7 +/- 5.5 mg/dL) in the control group versus 643 +/- 275 mumol/L (7.3 +/- 3.1 mg/dL) in the plasma exchange group. There was no significant difference between the two groups in mean serum creatinine, change in serum creatinine, change in reciprocal, or change in logarithm of serum creatinine at 1, 3, 6, or 12 months following randomization. Power calculation, assuming a 20% difference would be clinically relevant, was 0.94 at 12 months. There was significant morbidity in both groups; there were two deaths within 1 year of randomization, both of pulmonary infection and both in the plasma exchange group. We conclude that plasma exchange offers no additional therapeutic benefit to patients with idiopathic rapidly progressive glomerulonephritis (RPGN) who are not dialysis-dependent at presentation.