Guillevin L, Cevallos R, Durand-Gasselin B, Lhote F, Jarrousse B, Callard P
Hôpital Avicenne, University of Paris, France.
Ann Med Interne (Paris). 1997;148(3):198-204.
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 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.
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).
This study confirms that PE have no added benefit in the treatment of GN in MPA and CSS.
虽然血浆置换（PE）在使用类固醇（CS）±环磷酰胺（CY）治疗结节性多动脉炎（PAN）组血管炎时并无额外益处，但在患有肾小球肾炎（GN）的患者中尚未得到证实。因此，我们重新分析了患有GN的显微镜下多血管炎（MPA）或变应性肉芽肿性血管炎（CSS）患者的记录。
患者连续纳入2项随机试验：a）比较CS与CS + PE（n = 78），b）比较CS + 脉冲CY ± PE在预后不良因素的PAN和CSS中的应用（n = 62）；每位患者进行9 - 12次PE。
32例患者，18例男性和14例女性，患有GN，28例MPA和4例CSS，平均年龄53.2 ± 17岁。两组治疗前的临床/生物学表现相当：体重减轻84.4%，发热62.5%，多发性单神经炎62.5%，紫癜28.1%，胃肠道受累43.8%，关节炎37.5%，哮喘12.5%，中枢神经系统表现9.4%；心脏受累9.4%；平均肌酐血症为303 ± 286 μmol/l，所有病例均发现蛋白尿>0.5 g/l或1g/d，20/32例患者有镜下血尿，12/32例有白细胞尿。16例中有8例ANCA阳性，ELISA检测5例中有抗MPO抗体，3例中有抗PR3抗体。从未观察到HBV感染。治疗1年后，PE组的肌酐血症从374.4 ± 352降至290 ± 352 μmol/l，非PE组从287 ± 292降至170 ± 67（无统计学意义）。PE组6例患者和非PE组2例患者在治疗开始时进行透析。6例PE患者中有4例，2例未接受PE治疗的患者中有1例在1年后停止透析。此外，PE组1例患者出现肾衰竭复发，需要长期透析。PE组的5年生存率（4/19死亡）高于非PE组（7/13）。PE组的生存曲线为74%，非PE组为54%（无统计学意义）。
本研究证实PE在治疗MPA和CSS中的GN时无额外益处。
