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Effect of intensive plasma exchange (PE) in rapidly progressive crescentic glomerulonephritis (RPCGN)
Insights
New treatments like plasma exchange (PE) and methylprednisolone (MP) pulses significantly improved outcomes for patients with rapidly progressive crescentic glomerulonephritis (RPCGN), offering hope for this severe kidney disease.
Area of Science:
- Nephrology
- Immunology
- Internal Medicine
Background:
- Rapidly progressive crescentic glomerulonephritis (RPCGN) is a severe kidney disease characterized by extensive glomerular crescents and rapid GFR decline.
- RPCGN can be primary or associated with systemic diseases, presenting a significant clinical challenge.
- Historically, treatment with steroids and cyclophosphamide alone yielded poor outcomes.
Observation:
- Ten adult patients with severe RPCGN were treated with plasma exchange (PE), steroids (P), cyclophosphamide (C), and methylprednisolone (MP) pulses in 7 cases.
- Four patients were anuric at the start of treatment, requiring dialysis.
- The study observed the clinical and functional outcomes of this treatment regimen.
Findings:
- 80% of patients (8/10) showed therapeutic benefit, including reversal of GFR deterioration and substantial improvement.
- Two of four anuric patients regained kidney function.
- Patients with active cellular crescents had an 87.5% response rate, a significant improvement over historical controls (10%).
Implications:
- Plasma exchange (PE) and/or methylprednisolone (MP) pulses represent a promising therapeutic advance for RPCGN.
- These treatments offer improved outcomes compared to historical therapies, even in anuric patients.
- Further research is needed to delineate the specific contributions of PE and MP in combination therapy.
Abstract:
Ten adult patients with RPCGN (crescents in greater than 70% of glomeruli), primary in 6 and associated with systemic diseases in 4, were treated with PE, associated with oral steroids (P) and cyclophosphamide (C) in all cases and with intravenous methylprednisolone pulses (MP) in 7 cases. Four out of ten patients were anuric and needed dialysis treatment at the start of treatment. Therapeutic benefit, i.e. reversal of the trend to further deterioration and substantial improvement of GFR, was achieved in 8 out of 10 patients (80%), including 2 of 4 anuric patients, and in 7 of those (8) who had still active cellular crescents (87.5%). Similar therapeutic benefit had been achieved only in 10% of a comparable population of 10 patients with RPCGN treated before 1980 with P and C, without PE or MP pulses. It is difficult to establish whether the better therapeutic results in the more recently treated group were due to PE or to MP pulses of to both the new approaches, even though the clinical improvement obtained in all the 3 patients treated with PE without concomitant MP suggest a specific beneficial role for PE. RPCGN is a catastrophic illness characterized by progressive deterioration of kidney function, resulting in oliguria and uremia, usually within weeks or months. The most consistent histopathologic finding is the presence of extensive glomerular crescents resulting from proliferation of the extracapillary epithelial cell lining of Bowman's capsule. It is apparent that RPCGN is not a homogeneous entity, clinically, histologically or immunohistologically, but rather a clinicopathologic syndrome, the features of which may be seen in a variety of systemic disorders, including SLE, polyarteritis nodosa, Wegener's granulomatosis, Henoch-Schönlein purpura, cryoglobulinemia, and subacute bacterial endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)