Skip to content

Advertisement

  • Letter
  • Open Access

Effect of plasma exchange in acute respiratory failure due to Anti-neutrophil cytoplasmic antibody-associated vasculitis

Critical Care201822:328

https://doi.org/10.1186/s13054-018-2264-x

  • Received: 2 November 2018
  • Accepted: 15 November 2018
  • Published:

Abstract

Background

Acute respiratory failure related to diffuse alveolar hemorrhage (DAH) is a typical presentation of small-vessel vasculitis that requires prompt multidisciplinary management. The primary treatment is based on immunosuppressive drugs, whereas urgent plasma exchange has been proposed in case of life-threatening complications. We addressed the course of respiratory failure in 12 patients with ANCA-associated vasculitis-related DAH.

Patients and methods

Observational retrospective case series performed in the medical ICU of a tertiary hospital in Paris, France. Consecutive patients with ANCA-associated DAH admitted to our ICU for acute respiratory failure and treated by plasmapheresis were included in the analysis. We evaluated the SpO2/FiO2 ratio and assessed the mechanical ventilation mode hourly for 7 days.

Results

Twelve patients were included. Five of them required invasive mechanical ventilation. All patients were treated by plasma exchange in addition to a combination of glucocorticoids and immunosuppressive agents. Oxygenation improved over the first 7 days following initiation of plasma exchange, as shown by a dramatic increase in the median SpO2/FiO2 ratio from 183 [interquartile 137–321] to 353 [239–432] (p = 0.003), along with a decrease in the level of ventilatory support. All but one patient survived.

Conclusions

A multimodal induction regimen combining immunosuppressants and plasma exchange may rapidly reverse the respiratory dysfunction in ANCA-associated vasculitis-related DAH.

Besides infectious complications, severe acute flares of ANCA-associated vasculitis are common reasons that warrant ICU admission [1]. Plasma exchange (PLEX) has been proposed as an urgent adjuvant treatment in patients with life-threatening organ dysfunctions [2, 3]. In order to explore this question, we conducted a retrospective monocenter study in our tertiary ICU. We included patients admitted to the ICU for acute respiratory failure related to DAH, diagnosed as ANCA-associated vasculitis, and who received urgent initiation of PLEX. DAH was defined by bilateral infiltrates on chest X-ray and macroscopically bloody bronchoalveolar lavage with hemorrhagic and siderophagic alveoliitis. PLEX was performed daily with 1.2 plasma volume plasmapheresis primarily substituted with fresh frozen plasma and then albumin 5% and fresh frozen plasma when needed to maintain a prothrombin time > 50% and a fibrinogen level > 1.5 g/L. The main outcome was the evolution of oxygenation over the first seven days, using the SpO2/FiO2 ratio. We present data as median [interquartile range] or number (percentage) as appropriate. P for trend for continuous variables was calculated using a Cuzick test.

Between 2006 and 2014, 12 patients were treated by PLEX in the ICU for ANCA-vasculitis with respiratory symptoms (Table 1). All patients received high-dose corticosteroids (≥ 1 mg/kg prednisone-equivalent) and additional immunosuppressive drugs, either cyclophosphamide (nine within 24 h before or after ICU admission and one after ICU discharge) or rituximab administrated in the ICU (n = 2). One patient died from refractory multiple organ failure related to septic shock. Invasive mechanical ventilation was required in five patients (two received high-frequency oscillation ventilation). One patient received adjuvant nitric oxide. Duration of invasive mechanical ventilation ranged from 6 to 20 days. Three patients successfully received non-invasive ventilation. Oxygenation improved over the first week, as shown by the increase in the SpO2/FiO2 ratio from 183 [137–321] to 353 [239–432] (p value for trend 0.003), along with a decrease in the level of ventilatory support (Fig. 1). In contrast, only one out of five patients could be weaned off dialysis.
Table 1

Characteristics of patients

Variable

All patients

n = 12

Female gender

7 (58)

Age (years)

62.1 [49.3–71.6]

Small-vessel vasculitis

 Granulomatosis with polyangiitis

9 (75)

 Microscopic polyangiitis

3 (25)

Vasculitis flare as first manifestation of the disease

11 (92)

Previous maintenance treatments

 Corticosteroids

2 (16)

 Immunosuppressants

6 (50)

Organ involvement at ICU admission

 Pneumo-renal syndrome

9 (75)

 Respiratory SOFA component

3 [2–4]

 PaO2/FiO2 ratio

154 [61–386]

 PaCO2 (mmHg)

35 [31–46]

Acute kidney injury requiring RRT

5 (42)

 Renal SOFA component

2 [1–4]

 Blood creatinine level (μmol/L)

222 [94–450]

 Roteinuria (g/24 h)

1.5 [1.5–3]

 Hemoglobin level (g/dL)

10.1 [8.2–10.7]

Therapeutics received in the ICU

 Number of plasmapheresis courses

6 [4–7]

 Corticosteroids

12 (100)

 Immunosuppressants

12 (100)

 Invasive mechanical ventilation

5 (42)

ICU length of stay (days)a

11 [7–15]

In-ICU mortality

1 (8)

Continuous and categorical variables are described as median [interquartile range] and number (percentage), respectively

aIn-ICU length of stay in patients with and without mechanical invasive ventilation were 15 [9–17] and 7 [4–12] days, respectively (p = 0.03)

RRT renal replacement therapy, SOFA sequential organ failure assessment

Fig. 1
Fig. 1

Evolution of respiratory dysfunction as assessed every 12 h over the first 7 days (d1 to d7) from initiation of plasma exchange. Black dots and lines represent the SpO2/FiO2 ratio (median and interquartile range). Background histograms show the distribution of ventilatory support. NIV non-invasive ventilation, IMV invasive mechanical ventilation

In conclusion, this suggests the addition of PLEX results in fast respiratory recovery in most patients. This contrasts with the limited impact on renal function. The effects of PLEX are presumably related to fast removal of auto-antibodies as well as pro-inflammatory mediators likely to induce and/or sustain the increased permeability of the alveolo-capillar barrier.

Declarations

Acknowledgments

Not applicable.

Funding

GG was granted by the French Intensive Care Society.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Authors’ contributions

GG and FP designed the study. GG, FH, HM, and JM collected the data. GG performed the statistical analysis. GG and FP drafted the manuscript. BT, JPM, and LM critically revised the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The patients included in the study were not opposed to the anonymous use of collected data for research purposes.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Medical Intensive Care Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
(2)
Paris Descartes University, Paris, France
(3)
Department of Internal Medicine, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France

References

  1. Charlier C, Henegar C, Launay O, et al. Risk factors for major infections in Wegener granulomatosis: analysis of 113 patients. Ann Rheum Dis. 2009;68:658–63.View ArticlePubMedGoogle Scholar
  2. Guillevin L, Lhote F, Sauvaget F, et al. Treatment of polyarteritis nodosa related to hepatitis B virus with interferon-alpha and plasma exchanges. Ann Rheum Dis. 1994;53:334–7 Available from: http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=7912504&retmode=ref&cmd=prlinks.View ArticlePubMedGoogle Scholar
  3. Jayne DRW, Gaskin G, Rasmussen N, et al. Randomized trial of plasma exchange or high-dosage methylprednisolone as adjunctive therapy for severe renal vasculitis. J Am Soc Nephrol. 2007;18:2180–8.View ArticleGoogle Scholar

Copyright

© The Author(s). 2018

Advertisement