Comparison of double filtration plasmapheresis with immunoadsorption therapy in patients with anti-glomerular basement membrane nephritis

Abstract

BackgroundDouble filtration plasmapheresis (DFPP) and (IA) are both used to clear antibody. However, the clinical efficacy and safety of DFPP in patients with anti-glomerular basement membrane (anti-GBM) disease are unclear.MethodsThe 28 enrolled patients diagnosed serologically and pathologically with anti-GBM disease from 2003 to 2013 included 16 treated with DFPP and 12 with IA, with all patients administered immunosuppressive agents. DFPP consisted of an EC50W filter for plasma separation and an EC20W filter for plasma fractionation. A double volume of plasma was processed, and each patient received a 30–40 g human albumin supplement during each session. IA consisted of 10 cycles per session, with 8–10 sessions performed daily or every other day and each session regenerating 30–60 L of plasma. Serum anti-GBM antibodies and IgG were measured, and urinary and blood tests were performed, before and after each procedure. Renal function and outcome were determined.ResultsThe 28 patients consisted of 13 males and 15 females, of median age 44.5 years (range, 22.5–57 years). Six patients had pulmonary hemorrhage and 18 had serum creatinine concentrations >500 umol/L. The average serum creatinine concentration at early onset of disease was 525 umol/L while the peak concentration was 813 umol/L. All patients showed progressive increases in serum creatinine and required CRRT during the course of disease. Pathological examination showed an average 73.9% of crescents (range, 54.6–95.4%).The clinical and pathological features of the DPPP and IA groups were similar. Efficacy of clearing anti-GBM antibody was similar in the two groups (59.0 vs. 71.2%, P = 1.00), although fewer patients in the DFPP group experienced reduced IgG (62.7 vs. 83.5%, p = 0.002). One patient each had a pulmonary hemorrhage and a subcutaneous hemorrhage during treatment, but there were no other serious complications. At the end of follow-up, patient survival and renal survival were similar in the DFPP and IA groups.ConclusionDPPP plus immunosuppressive therapy efficiently and safely removed anti-GBM antibodies. The fewer plasma-associated side effects and reduced loss of IgG suggest that DFPP may be a better treatment choice for anti-GBM disease, especially in patients with insufficient plasma.

Plasmapheresis exerts a long‐lasting antipruritic effect in severe cholestatic itch

“…Although plasmapheresis is an invasive procedure and might be associated with side effects, it is associated with a favourable safety profile, regardless of the original indication. [8][9][10] Our study confirmed a very good safety profile of this method.…”

“…To the best of our knowledge, the two largest series to date both comprised five patients with PBC, both reporting significant improvement of pruritus. Although plasmapheresis is an invasive procedure and might be associated with side effects, it is associated with a favourable safety profile, regardless of the original indication . Our study confirmed a very good safety profile of this method.…”

Complication from Desensitization

“…Zhang et al [75] analyzed the 28 enrolled patients diagnosed serologically and pathologically with anti-GBM disease from 2003 to 2013 in whom 16 treated with DFPP and 12 with IA, A double volume of plasma was processed, and each patient received a 30-40 g human albumin supplement during each session. IA consisted of 10 cycles per session, with 8-10 sessions performed daily or every other day and each session regenerating 30-60 L of plasma.…”

Was sind die Indikationen für Rescue-Verfahren?

“…Die Daten zur Prognose von ANCA-positiven Patienten mit Anti-GBM-Erkrankung sind uneinheitlich -es wurden sowohl eine höhere als auch niedrige Wahrscheinlichkeit eines Erhalts der Nierenfunktion bei positivem ANCA berichtet [3,15,44]. Ergebnisse einer Kohortenstudie an 28 Patienten konnten zeigen, dass eine Immunadsorption im Vergleich zu einer Doppelfiltrationsplasmapherese nicht zu einem besseren therapeutischen Ergebnis (Entfernung von Anti-GBM-Antikörper) führte, aber mit einem höheren Gesamt-IgG-Verlust assoziiert war [75]. Die Leitlinien der KDIGO (Kidney Disease: Improving Global Outcomes) empfehlen, bei Patienten mit akuter Anti-GBM-Erkrankung zusätzlich zur Immunsuppression mit CYC (oral 2-3 mg/kg plus Prednisolon) eine Plasmapherese als First-Line-Therapie durchzuführen, bis die Anti-GBM-Antikörper im Serum nicht mehr nachweisbar sind [55].…”