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01.12.2018 | Letter | Ausgabe 1/2018 Open Access

Critical Care 1/2018

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

Zeitschrift:
Critical Care > Ausgabe 1/2018
Autoren:
Guillaume Geri, Benjamin Terrier, Farhad Heshmati, Hanafi Moussaoui, Julien Massot, Jean-Paul Mira, Luc Mouthon, Frédéric Pène
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 SpO 2/FiO 2 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 SpO 2/FiO 2 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]
 PaO 2/FiO 2 ratio
154 [61–386]
 PaCO 2 (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
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.

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.

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.

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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.
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