【持续性肾脏替代治疗crrt英文精品课件】tuesday clinical case conference

Tuesday Clinical Case Conference,Zae Kim,Therapy of ANCA-Associated Small Vessel Vasculitis,Introduction,Best known induction therapy Cyclophosphamide / Steroid Search for alternative induction agent NORAM Minimizing the use of CYC Oral vs IV CyA - CYCLOPS CYCAZAREM (cyclophosphamide vs azathioprine for early remission phase of vasculitis),Cyclophosphamide / Steroid,Mainstay of treatment for both MPA and WG since 1980s High rate of remission Significant morbidity Hemorragic cystitis Bladder cancer Myelodysplasia Infertility infection,What are the approaches to maintaining remission without CYC?,NORAM,Randomized Trial of Cya vs Mtx for Induction of Remissioi nin early systemic ANCAAV_de groot_ArthRheu_2005,NORAM remission at 6 months,Randomized Trial of Cya vs Mtx for Induction of Remissioi nin early systemic ANCAAV_de groot_ArthRheu_2005,NORAM - relapses,Randomized Trial of Cya vs Mtx for Induction of Remissioi nin early systemic ANCAAV_de groot_ArthRheu_2005,Minimizing exposure to CYC,Minimizing the use of CYC Induction Oral vs IV CyA - CYCLOPS Maintenance CYCAZAREM (cyclophosphamide vs azathioprine for early remission phase of vasculitis) MMF?,Which is better: Oral or IV CYC?,Guillevin L et al, Arthritis Rheum, 1997 RCT of patients with WG,CYC: oral vs pulse IV, meta analysis,Meta-analysis 11 non-randomized studies N = 202 patients Pulse vs daily oral Cya No difference in death / ESRD / remission More relapses OR 1.79* (CI 0.85-3.75) Less infections RR 0.45 Lower dose 17 g vs. 35 g *not statistically significant,K de Groot et al. Nephrol Dial Transplant 2001; 16:2018-27,CYC: Is IV pulse as effective as PO CYC?,CYCLOPS Time to remission,Cyclops Time to relapse,Minimizing exposure to CYC,Minimizing the use of CYC Induction Oral vs IV CyA - CYCLOPS Maintenance CYCAZAREM (cyclophosphamide vs azathioprine for early remission phase of vasculitis) MMF?,CYCAZAREM trial,Jayne et al, NEJM, 349;1, 2003,CYCAZAREM - remission,Jayne et al, NEJM, 349;1, 2003,Time to first relapse,Jayne et al, NEJM, 349;1, 2003,CYCAZAREM renal recovery,Jayne et al, NEJM, 349;1, 2003,CYCAZAREM - conclusion,No difference in relapse rate CTX (14%) vs AZA (15%) Only predictor of relapse was MPA (8%) vs WG (18%) No difference in serious adverse events,Alternative to AZA as maintenance therapy,MTx / Leflunomide Metzler et al, Rheumatology 2007 55 patients with generalized WG Study terminated early 2/2 higher rate of relapse in MTx group high rate of adverse event in Leflunomide IMPROVE by EUVAS MMF vs AZA,Ongoing trials at EUVAS,Length of long-term immunosuppressive therapy? REMAIN long-term low dose immunosuppression versus treatment withdrawal for renal vasculitis Alternative induction agent? MYCYC (Randomized clinical trial of MMF vs CYC for r