Rituximab versus intravenous cyclophosphamide for anti-neutrophil cytoplasmic antibody-associated vasculitis with severe renal impairment: a multicentre REVEAL cohort study

Objectives To compare the efficacy and safety of rituximab (RTX) to those of intravenous cyclophosphamide (IVCY) as remission induction therapy in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) and severe renal impairment. Methods Using the REVEAL cohort, this retrospective multicentre study enrolled 96 newly diagnosed patients with AAV and an estimated glomerular filtration rate of <30 mL/min/1.73 m2. The patients were divided into RTX and IVCY groups. Matching weights were used to adjust for baseline characteristics. The primary outcome was a 2-year composite of all-cause mortality or end-stage kidney disease (ESKD). Secondary outcomes included all-cause mortality, ESKD, relapse, and hospitalisation-requiring infections. Outcomes were assessed using multivariable Cox proportional hazards models. Results In the weighted population, the hazard ratio (HR) for RTX versus IVCY was 0.73 (95% confidence interval: 0.31–1.72) for the primary composite outcome, with no significant intergroup difference. Similarly, intergroup differences in the HRs for all-cause mortality, ESKD, relapses, and hospitalisation-requiring infections were not significant. Conclusions RTX and IVCY demonstrated comparable efficacy in preventing mortality and ESKD in this high-risk population. RTX is a viable option for patients with AAV and severe renal impairment.