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.
Complement inhibitors are expanding their indications in nephrology. In patients with type 2 diabetes, semaglutide prevents chronic kidney disease (CKD), while retatrutide reduces albuminuria in patients with diabetes and established CKD. Obinutuzumab improves the renal response in patients with lupus nephropathy. A double dose of icodextrin did not reduce mortality, peritonitis, or hospitalization rates compared to standard peritoneal dialysis treatment, though it increased ultrafiltration. In patients on hemodialysis, using a dialysate with an intermediate potassium concentration combined with a potassium chelator appears to stabilize serum potassium levels and reduce the occurrence of arrhythmias. Xenotransplantation and ex vivo perfusion techniques are being perfected in the search for a solution to organ shortage.
Despite improved survival in recent years, long-term outcomes in patients surviving progressive multifocal leukoencephalopathy beyond the first year remain poorly defined. This international multicenter retrospective study aimed to characterize the three-year prognosis of patients with progressive multifocal leukoencephalopathy who had survived at least one year, identify factors associated with favorable outcomes and late mortality, and determine recurrence rate. Data were collected through standardized questionnaires across forty-one centers in twelve countries. Patients were eligible if they met the 2013 diagnostic criteria for definite progressive multifocal leukoencephalopathy of the American Academy of Neurology, survived at least one year after diagnosis, and had documented follow-up three years after diagnosis. Demographic, clinical, virological, and radiological data were retrieved at diagnosis, one year, and three years. Functional status was assessed using the modified Rankin Scale, with scores of 0-2 defining a favorable outcome. Generalized linear mixed models identified independent predictors of three-year functional status and late mortality. Among 1877 screened cases, 245 patients met inclusion criteria. The most common underlying causes of immunosuppression were HIV infection (48%), autoimmune/inflammatory diseases (26%), and hematological malignancies (18%). At three years, 220 patients (89.8% of the cohort) were alive and 188 (85.5% of survivors) had neurological sequelae, most frequently motor or cognitive impairment. Overall, 112/245 (45.7%) achieved a favorable functional outcome. HIV-associated progressive multifocal leukoencephalopathy (OR 2.36, 95% CI 1.05-5.28) was associated with a favourable outcome, whereas higher modified Rankin Scale score at diagnosis (OR 0.48, 95% CI 0.35-0.66) and higher number of affected brain regions on baseline MRI (OR 0.78, 95% CI 0.64-0.95) were independently associated with poorer functional outcome. Among variables collected one year after diagnosis, good functional status at that time was significantly associated with long-term favorable outcome (OR 0.01, 95% CI <0.01-0.03). Twenty-five patients (10.2%) died after the first year, with mortality associated with higher lesion burden at diagnosis and primary immunodeficiency as underlying disease. Even beyond the first year, progressive multifocal leukoencephalopathy remained the leading cause of death (11/25). Recurrence occurred in seven patients (2.9%) and was almost always fatal (6/7). This study provides a comprehensive evaluation of long-term outcomes among survivors of progressive multifocal leukoencephalopathy. These findings present a nuanced picture: while most remain neurologically impaired, nearly half achieve functional independence at three years. The results emphasize the prognostic relevance of the initial clinical and radiological burden and early functional trajectory and highlight the need for research into mechanisms driving disease recurrence.
Older adults, with complex needs and an elevated risk of complications, account for a high proportion of emergency visits in France. Mobile geriatric teams (MGTs) and the emergency geriatric medicine unit (EGMU) based in the emergency department (ED) have been developed to improve care. Although the EGMU reduces hospitalizations and readmissions, its cost-effectiveness remains uncertain. This study assessed the incremental cost-effectiveness ratio (ICER) of the EGMU compared to the MGT unit. In all, 338 older patients were included: 102 managed by the MGT unit in January 2014 and 236 in the EGMU in January 2015, which replaced the MGT unit. The primary efficacy endpoint was the rate of readmission to the ED within 30 days (30DRA). We conducted the analysis from the payer’s perspective, incorporated a Monte Carlo simulation, and generated a cost-effectiveness acceptability curve. The average cost per patient was estimated to be €5,738.16 in the EGMU, compared to €6,701.35 in the MGT unit. The mean 30DRA was 0.09 for the EGMU and 0.13 for the MGT unit. The ICER was €24,079 per readmission avoided (RA). The probability that the EGMU would be cost-effective at a willingness-to-pay threshold of €33,622.84 per RA was 63.26
