INDICATIONS FOR PLASMA-EXCHANGE IN THE TREATMENT OF POLYARTERITIS-NODOSA, CHURG-STRAUSS-SYNDROME AND OTHER SYSTEMIC VASCULITIDES

Since 1977, plasma exchanges (PE) have been proposed to treat immune-m ediated disease, especially when an immune complex-induced mechanism i s suspected, including vasculitis and particularly polyarteritis nodos a (PAN) and Churg-Strauss syndrome (CSS). The rationale for the use of PE is to remove circulating pathogenic factors, such as immune comple xes and their components (antigens and antibodies). The indications of PE in the treatment of PAN without hepatitis B virus (HBV) infection and CSS have recently been clarified by two prospective therapeutic st udies. There is presently no argument to support the systematic prescr iption of PE at the time of diagnosis of PAN without HBV infection and CSS, even for patients with factors of poor prognosis. PE may be usef ul as a second-line treatment in patients with refractory vasculitis a nd sometimes allowed, in association with corticosteroids and immunosu ppressive drugs, recovery from PAN in some clinically severely comprom ised patients. HBV-related PAN is the best indication of PE in the tre atment of PAN and is, in combination with antiviral. therapy, the firs t-line treatment of this particular form of vasculitis. Among 41 patie nts with HBV-related PAN treated with PE and antiviral therapy (vidara bine in 35, interferon-alpha 2b in 6), the 7 year survival rate was 83 %. HBeAg/HBeAb seroconversion was obtained in 51.2% and clearance (HBe Ag/HBeAb HBsAg/HBsAb seroconversions) was seen in 24.4%. These results are much better than those obtained under corticosteroids +/- cycloph osphamide +/- PE, with which seroconversion was rare. There are presen tly no convincing data to support the prescription of PE in Wegener's granulomatosis and microscopic polyangiitis, even in the more severe f orms, except in dialysis-dependent patients and further prospective tr ials are needed to determine the therapeutic value of PE, especially f or severe glomerulonephritis in anti-neutrophil cytoplasmic antibody-a ssociated systemic vasculitis. Side effects of PE in the treatment of PAN and CSS became more rare with technological improvements. In our e xperience of 182 patients with PAN and CSS treated with PE, none died during a session and the side effects and complications due to PE were usually mild and transient. Copyright (C) 1996 Elsevier Science Ltd.