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ANCA Vasculitis — SCE Rheumatology MCQ

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HardVasculitisANCA VasculitisSCE Rheumatology

A 45-year-old man has newly diagnosed microscopic polyangiitis with biopsy-proven pauci-immune necrotising crescentic glomerulonephritis. His serum creatinine has risen from 220 to 450 micromol/L over 5 days, with haematuria and red-cell casts. Anti-glomerular basement membrane antibodies are negative, and he does not have pulmonary haemorrhage. Remission induction with rituximab and a reduced-dose glucocorticoid regimen has commenced. According to the 2025 British Society for Rheumatology recommendations, which additional intervention may be considered specifically because of his high risk of kidney failure, after balancing potential benefit against treatment-related adverse events?

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Correct answer: D — Plasma exchange

Plasma exchange is correct. The BSR 2025 GPA/MPA algorithm permits plasma exchange in selected patients with serum creatinine above 300 micromol/L because of active glomerulonephritis, particularly when kidney function is rapidly deteriorating. Its potential reduction in short-term kidney-failure risk must be balanced against adverse effects, notably serious infection; it is not routine for every patient with AAV. Avacopan is an important adjunct to rituximab or cyclophosphamide as part of a glucocorticoid-sparing strategy, but the severe renal-risk feature in this stem specifically tests the conditional indication for plasma exchange. Mycophenolate is not the preferred additional induction treatment for severe organ-threatening disease. Intravenous immunoglobulin may occasionally be used when conventional immunosuppression is unsuitable or for refractory disease, while eculizumab is not standard induction therapy for GPA or MPA.

Reference: British Society for Rheumatology, The 2025 British Society for Rheumatology management recommendations for ANCA-associated vasculitis, GPA/MPA treatment algorithm, 2025. https://pubmed.ncbi.nlm.nih.gov/40499922/