Rheumatological Conditions and TPE, Therapeutic plasma exchange, Clinical Pathology - Full Vignette

Описание: An 86-year-old man develops progressive fatigue, dark urine, hemoptysis, and acute kidney injury following recent medication therapy, with exam findings of pale conjunctivae and pulmonary crackles, and lab results showing anemia, renal dysfunction, and positive MPO-ANCA. What clinical features and recent evidence should guide your decisions regarding advanced interventions in this complex case? How has expert guidance evolved regarding severe pulmonary-renal presentations?

VIDEO INFO
Category: Rheumatological Conditions and TPE, Therapeutic plasma exchange, Clinical Pathology
Difficulty: Expert - Expert level - For those seeking deep understanding
Question Type: Recent Changes
Case Type: Rare Presentation

Explore more ways to learn on this and other topics by going to https://endlessmedical.academy/auth?h...

QUESTION
An 86-year-old man presents with progressive fatigue, dark urine, recurrent small-volume hemoptysis, and acute kidney injury. Medications: hydralazine 25 mg three times daily started 3 months ago, amlodipine 5 mg daily, pantoprazole 40 mg daily, cholecalciferol 1,000 IU daily, and a multivitamin. He neither smokes nor uses illicit drugs and reports 1-2 alcoholic beverages weekly. He is celibate and lives independently....

OPTIONS
A. Do not routinely add TPE for severe AAV with diffuse alveolar hemorrhage or active pauci-immune glomerulonephritis; per the 2021 ACR/Vasculitis Foundation guideline and the 2024 EULAR update, reserve TPE for selected very high end-stage kidney disease risk or salvage situations and for anti-GBM o...
B. Add TPE for all AAV cases with eGFR less than 50 mL/min/1.73 m^2 or any alveolar hemorrhage, performing 1.5 plasma-volume exchanges daily for 10 sessions because randomized trials demonstrate a clear survival advantage across subgroups.
C. Restrict TPE to PR3-ANCA disease and avoid it in MPO-ANCA; perform 10-12 exchanges at 1.5 plasma volumes using albumin exclusively even with diffuse alveolar hemorrhage to minimize bleeding.
D. Delay rituximab or cyclophosphamide and use stand-alone TPE for 7 days until anti-GBM results return, since early immunosuppression may confound serologies and outcomes in pulmonary-renal syndromes.

CORRECT ANSWER
A. Do not routinely add TPE for severe AAV with diffuse alveolar hemorrhage or active pauci-immune glomerulonephritis; per the 2021 ACR/Vasculitis Foundation guideline and the 2024 EULAR update, reserve TPE for selected very high end-stage kidney disease risk or salvage situations and for anti-GBM overlap. If used, exchange ~1.0 plasma volume daily for 5-7 sessions, favoring plasma when bleeding/coagulopathy is prominent.

EXPLANATION
PEXIVAS showed no overall reduction in death or end-stage kidney disease with therapeutic plasma exchange in severe ANCA-associated vasculitis, including patients with diffuse alveolar hemorrhage. Accordingly, the 2021 American College of Rheumatology/Vasculitis Foundation guideline and the 2024 EULAR update do not recommend routine TPE for severe AAV with DAH or active pauci-immune glomerulonephritis. The contemporary approach is to reserve TPE for selected circumstances such as anti-GBM overlap, salvage in exceptionally high end-stage kidney disease risk, or specific clinical scenarios where rapid antibody removal is plausibly beneficial. When TPE is used, a standard prescription is about one plasma volume daily for 5-7 sessions, with fresh frozen plasma favored when bleeding or coagulopathy is prominent.

The distractors reflect outdated or misapplied practices....


Further reading:

Links to sources are provided for optional further reading only. The questions and explanations are independently authored and do not reproduce or adapt any specific third-party text or content.

---------------------------------------------------

Our cases and questions come from the https://EndlessMedical.Academy quiz engine - multi-model platform. Each question and explanation is forged by consensus between multiple top AI models (i.e. Open AI GPT, Claude, Grok, etc.), with automated web searches for the latest research and verified references. Calculations (e.g. eGFR, dosages) are checked via code execution to eliminate errors, and all references are reviewed by several AIs to minimize hallucinations.

Important note: This material is entirely AI-generated and has not been verified by human experts; despite stringent consensus checks, perfect accuracy cannot be guaranteed. Exercise caution - always corroborate the content with trusted references or qualified professionals, and never apply information from this content to patient care or clinical decisions without independent verification.

Clinicians already rely on AI and online tools - myself included - so treat this content as an additional focused aid, not a replacement for proper medical education. Visit https://endlessmedical.academy for more AI-supported resources and cases.

This material can not be treated as medical advice. May cont