Therapeutic Apheresis for Renal Disorders

Abstract

This review summarizes the clinical evidence and practical details for the use of plasmapheresis and other apheresis modalities for each indication in nephrology. Updated information on the molecular biology and immunology of each renal disease is discussed in relation to the rationale for apheresis therapy and its place amid other available treatments. Autoantibody-mediated diseases, such as anti-GBM (anti-glomerular basement membrane) glomerulonephritis (GN), ANCA (antineutrophil cytoplasmic antibody)-related GN and the antibody-mediated type of TTP (thrombotic thrombocytopenic purpura), and alloantibody-mediated diseases such as kidney transplant sensitization and humoral rejection, can be treated by various plasmapheresis methods. These include standard plasmapheresis with a replacement volume, or plasmapheresis with online plasma purification using adsorption columns or secondary filtration. However, it should be noted that the pathogenic molecules implicated in FSGS (focal segmental glomerulosclerosis), myeloma cast nephropathy, and perhaps other diseases are too small to be removed by most online purification methods. A great majority of controlled trials and series on which evidence-based treatment recommendations are made were performed using centrifugal plasmapheresis; it is presumed that membrane-separation plasmapheresis is equally efficacious. For some rarer diseases, such as MPGN (membranoproliferative GN) type 2 with factor H abnormalities or C3Nef (C3 nephritic factor) autoantibodies, there are only a few case reports, but enough scientific understanding to warrant a trial of plasmapheresis in severe cases. Photopheresis, which is effective for cell-mediated rejection in heart and lung transplantation, has not yet found a place in the routine treatment of kidney transplant rejection.

Principles of Separation

“…It is most appropriate for patients with active moderate to severe cryoglobulinemia, including membranoproliferative GN, neuropathy, arthralgias, or ulcerating purpuric lesions (42). Case series and reports, but no randomized trials, support the use of TPE in cryoglobulinemia, performed with warmed lines and replacement fluids to prevent precipitation (4,43).…”

“…Most clinical trial evidence on safety and efficacy of TPE has subsequently come from studies using centrifugation separation technology. Nonetheless, membrane separation is assumed to have similar efficacy in most conditions (4). Operational contrasts between centrifugation and membrane filtration, the two major technologies used to achieve TPE, are outlined in Table 2.…”

Rescue of kidney function in a toddler with anti-GBM nephritis

“…Initially, human plasma was used as exchange fluid to reduce bleeding complications after the procedures of kidney biopsy and dialysis catheter implantation. PE therapy was maintained until kidney function was stabilized and anti-GBM levels remained low, as often seen after 14 days [12]. The anti-GBM antibody levels remained low thereafter, indicating efficient removal.…”

Plasmapheresis Therapy in Renal Transplant Patients

“…Plazmaferez tedavisi antikorlar, immünkompleksler, krioglobulinler, myeloma hafif zincirleri, endotoksinler ve kolesterol içeren lipoproteinler gibi büyük molekül ağırlıklı maddeleri plazmadan temizlemek için kullanılan bir yöntemdir (1,2). Böbrek nakli hastalarında plazmaferez yöntemi olarak; plazma değişimi (PD), çift filtrasyon plazmaferezis (ÇFPF) ve immünadsorbsi-yon gibi farklı yöntemler kullanılmaktadır.…”