Plasma exchange for severe alveolar hemorrhage in ANCA-associated vasculitis: emulation of a target trial
Year: 2026
Type: article
Abstract: RATIONALE: Patients with severe antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV)-related diffuse alveolar hemorrhage (DAH) face high mortality. In the PEXIVAS trial, plasma exchange (PLEX) did not reduce death or end-stage kidney disease, but only 9% had severe DAH. OBJECTIVES: This study aimed to assess whether PLEX lowers mortality in patients with severe DAH. METHODS: We emulated a target trial using retrospective data from a national multicenter cohort of patients with severe AAV-related DAH. The primary endpoint was 30-day mortality after intensive care unit (ICU) admission, analyzed using a Cox model adjusted for prespecified confounders. MEASUREMENTS AND MAIN RESULTS: We included 184 patients (median age 66 [53-75] years; 51% female; 51% with granulomatosis with polyangiitis; 53% MPO (Myeloperoxydase)-ANCA positive). Of these, 144 (78.3%) received PLEX, and 40 (21.7%) did not. Baseline characteristics were similar, except for more severe renal impairment (creatinine 357 vs 171 µmol/L, P = .01) and more frequent cyclophosphamide use (77% vs 55%, P = .01) in the PLEX group. Severity at ICU admission (median Simplified Acute Physiology Score II score: 42) and mechanical ventilation needs (54%) were comparable between groups. At 30 days, overall survival was 85%. No significant difference in mortality was observed between the PLEX and no-PLEX groups: 30-day survival was 85% (95% CI, 81-90) with PLEX vs 88% (95% CI, 77-96) without (hazard ratio, 1.23; 95% CI, 0.57-3.89). Secondary outcomes were also similar. CONCLUSIONS: In this emulated target trial, PLEX did not reduce 30-day mortality in patients with severe AAV-related DAH.
Authors: Anne-Claire Sanna, Ségolène Gendreau, Cyrielle Desnos, Romain Lombardi, Jolan Malherbe, Dimitri Titeca-Beauport, Florian Reizine, Guillaume Louis, Kladoum Nassarmadji, Julien Campagne, Jean-Philippe Martellosio, Alban Deroux, Eddine Bendiab, Valentin Coirier, Jennifer Catano, Marc Pineton De Chambrun, Maxime Samson, Clara Vigneron, Antoine Néel, Perrine Smets, Thylbert Deltombe, Benoit Brilland, Maxime Desgrouas, Olivier Simon, Stanislas Faguer, Stéphane Giorgiutti, Romain Paule, François Arrive, Ingrid Masson, Thomas Quéméneur, Cécile-Audrey Durel, Etienne de Montmollin, Jean-Pierre Quenot, François Perrin, Hervé Lobbes, Quentin Lajoye, Rafik Mesbah, Roderau Outh, Benjamin Thoreau, Adeline Lacraz, Carole Philipponnet, Damien Contou, Fabien Parazols, Florian Garo, Gauthier Blonz, Grégoire Ducoux, Halil Yildiz, Isabelle Rey, Ludovic Di Ascia, Nahema Issa, Pierre Le Guen, Viviane Queyrel, Rita Eid, Robin Arcani, Yurdagul Uzunhan, Xavier Puéchal, Raphaël Porcher, Nicolas de Prost, Benjamin Terrier, French Vasculitis Study Group (FVSG) and the Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie (GrrrOH)
Institutions: Université Paris Cité, Hôpital Cochin, Assistance Publique – Hôpitaux de Paris, Université Paris-Est Créteil, Hôpitaux Universitaires Henri-Mondor, Institut Mondor de Recherche Biomédicale, Sorbonne Université, Hôpital Tenon, Centre Hospitalier Universitaire de Nice, Centre Hospitalier Universitaire de Caen Normandie, Centre Hospitalier Universitaire Amiens-Picardie, Centre hospitalier Bretagne Atlantique, Centre Hospitalier Régional de Metz-Thionville, Hôpital Saint-Louis, Centre Hospitalier Universitaire de Poitiers, Centre Hospitalier Universitaire de Grenoble, Hôpital Lapeyronie, Centre Hospitalier Universitaire de Rennes, Pitié-Salpêtrière Hospital, CHU Dijon Bourgogne, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire de Clermont-Ferrand, Centre Hospitalier Universitaire de La Réunion, Centre Hospitalier Universitaire d'Angers, Centre hospitalier universitaire d'Orléans, Centre Hospitalier Universitaire de Toulouse, Hôpitaux Universitaires de Strasbourg, Hôpital Foch, Centre Hospitalier Universitaire de Saint-Étienne, Centre Hospitalier de Valenciennes, Centre Hospitalier Saint-Joseph Saint-Luc, Hôpital Bichat-Claude-Bernard, Centre Hospitalier Saint-Nazaire, Centre Hospitalier Universitaire de Bordeaux, Hôpital Pellegrin, Centre Hospitalier de Boulogne sur Mer, Centre Hospitalier de Perpignan, Centre Hospitalier de la Côte Basque, Centre Hospitalier Victor Dupouy, Centre Hospitalier Universitaire de Nîmes, Hôpital Edouard Herriot, Cliniques Universitaires Saint-Luc, Centre Hospitalier Annecy Genevois, Hôpital Saint-André, Hôpital Pasteur, Bicêtre Hospital, Assistance Publique Hôpitaux de Marseille, Hôpital de la Timone, Hôpital Avicenne, Hôtel-Dieu de Paris, Inserm
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W7125473197