Does plasma exchange have a role in ANCA-associated vasculitis? Viewpoint 2: plasma exchange may be useful under some circumstances.

The use of plasma exchange (PLEX) as adjunct therapy in the initial management of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis remains to be discussed controversially in light of present evidence. In our Viewpoint we highlight scenarios where we think that physicians might still consider the use of PLEX, such as the most severe presentation forms including diffuse alveolar haemorrhage (DAH) with hypoxaemia and acute glomerulonephritis with significantly impaired kidney function. Recent sub-analyses of the PEXIVAS trial have focused on these patient populations and have provided outcomes of these patients. It became obvious that the mortality rates of those presenting with DAH were non-significantly lower and patients with severe GN show a trend of more pronounced estimated glomerular filtration rate (eGFR) recovery in the first weeks after PLEX. Notably, more patients reach a kidney function recovery as defined as eGFR increase ≥15 ml/min/1.73 m2 from baseline to week 52 when randomised to PLEX. These beneficial outcomes need to be balanced against the increased risk of serious infections and we recommend an individualized decision-making when considering addition of PLEX in the induction therapy.