Plasmapheresis has been used in the management of immunologic renal disease for the last 40 years. The rationale behind this approach is to remove pathogenic immune mediators, such as autoantibodies and immune complexes, from the circulation. There may also be benefit in depleting proinflammatory molecules, such as complement components and coagulation factors. Initial experience was gained in Goodpasture’s disease, in which antiglomerular basement membrane antibodies were known to be pathogenic. More recently, a role for autoantibodies has become clear in small-vessel systemic vasculitis and some cases of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura. Removal of immune complexes is thought to be important in cryoglobulinemia and systemic lupus erythematosus. Plasmapheresis is used in renal transplantation for the treatment of acute antibody-mediated rejection, and for desensitization of patients with preformed anti-HLA antibodies or those receiving an ABO-incompatible transplant. Although many of the early studies were uncontrolled, there has been an increasing number of randomized controlled trials in recent years. The aim of this article is to summarize current indications for the use of plasmapheresis in immunologic renal disease.

1.
Lockwood CM, Boulton-Jones JM, Lowenthal RM, Simpson IJ, Peters DK: Recovery from Goodpasture’s syndrome after immunosuppressive treatment and plasmapheresis. Br Med J 1975;2:252–254.
2.
Baweja S, Wiggins K, Lee D, Blair S, Fraenkel M, McMahon LP: Benefits and limitations of plasmapheresis in renal diseases: an evidence-based approach. J Artif Organs 2011;14:9–22.
3.
Szczepiorkowski ZM, Bandarenko N, Kim HC, et al: Guidelines on the use of therapeutic apheresis in clinical practice: evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis. J Clin Apher 2007;22:106–175.
4.
Shaz BH, Linenberger ML, Bandarenko N, et al: Category IV indications for therapeutic apheresis: ASFA fourth special issue. J Clin Apher 2007;22:176–180.
5.
Derksen RH, Schuurman HJ, Meyling FH, Struyvenberg A, Kater L: The efficacy of plasma exchange in the removal of plasma components. J Lab Clin Med 1984;104:346–354.
6.
Jayne DR, Gaskin G, Rasmussen N, et al: Randomized trial of plasma exchange or high-dosage methylprednisolone as adjunctive therapy for severe renal vasculitis. J Am Soc Nephrol 2007;18:2180–2188.
7.
Levy J, Pusey CD: Plasma exchange; in Johnson RJ, Floege J, Feehally J (eds): Comprehensive Clinical Nephrology, ed 3. London, Harcourt Publishers, 2007, pp 1013–1020.
8.
Reutter JC, Sanders KF, Brecher ME, Jones HG, Bandarenko N: Incidence of allergic reactions with fresh frozen plasma or cryo-supernatant plasma in the treatment of thrombotic thrombocytopenic purpura. J Clin Apher 2001;16:134–138.
9.
Norda R, Stegmayr BG: Therapeutic apheresis in Sweden: update of epidemiology and adverse events. Transfus Apher Sci 2003;29:159–166.
10.
Rock G, Clark B, Sutton D: The Canadian Apheresis Registry. Transfus Apher Sci 2003;29:167–177.
11.
Stegmayr B, Ptak J, Wikstrom B, et al: World Apheresis Registry 2003–2007 data. Transfus Apher Sci 2008;39:247–254.
12.
Pusey C, Dash C, Garrett M, et al: Experience of using human albumin solution 4.5% in 1195 therapeutic plasma exchange procedures. Transfus Med 2010;20:244–249.
13.
Pusey CD: Anti-glomerular basement membrane disease. Kidney Int 2003;64:1535–1550.
14.
Johnson JP, Whitman W, Briggs WA, Wilson CB: Plasmapheresis and immunosuppressive agents in antibasement membrane antibody-induced Goodpasture’s syndrome. Am J Med 1978;64:354–359.
15.
Levy JB, Turner AN, Rees AJ, Pusey CD: Long-term outcome of anti-glomerular basement membrane antibody disease treated with plasma exchange and immunosuppression. Ann Intern Med 2001;134:1033–1042.
16.
Pusey CD, Rees AJ, Evans DJ, Peters DK, Lockwood CM: Plasma exchange in focal necrotizing glomerulonephritis without anti-GBM antibodies. Kidney Int 1991;40:757–763.
17.
Szpirt WM, Heaf JG, Petersen J: Plasma exchange for induction and cyclosporine A for maintenance of remission in Wegener’s granulomatosis – a clinical randomized controlled trial. Nephrol Dial Transplant 2011;26:206–213.
18.
Walsh M, Catapano F, Szpirt W, et al: Plasma exchange for renal vasculitis and idiopathic rapidly progressive glomerulonephritis: a meta-analysis. Am J Kidney Dis 2011;57:566–574.
19.
Klemmer PJ, Chalermskulrat W, Reif MS, Hogan SL, Henke DC, Falk RJ: Plasmapheresis therapy for diffuse alveolar hemorrhage in patients with small-vessel vasculitis. Am J Kidney Dis 2003;42:1149–1153.
20.
Deegens JK, Andresdottir MB, Croockewit S, Wetzels JF: Plasma exchange improves graft survival in patients with recurrent focal glomerulosclerosis after renal transplant. Transpl Int 2004;17:151–157.
21.
Gonzalez E, Ettenger R, Rianthavorn P, Tsai E, Malekzadeh M: Preemptive plasmapheresis and recurrence of focal segmental glomerulosclerosis in pediatric renal transplantation. Pediatr Transplant 2011;15:495–501.
22.
Feld SM, Figueroa P, Savin V, et al: Plasmapheresis in the treatment of steroid-resistant focal segmental glomerulosclerosis in native kidneys. Am J Kidney Dis 1998;32:230–237.
23.
Lewis EJ, Hunsicker LG, Lan SP, Rohde RD, Lachin JM: A controlled trial of plasmapheresis therapy in severe lupus nephritis. The Lupus Nephritis Collaborative Study Group. N Engl J Med 1992;326:1373–1379.
24.
Danieli MG, Palmieri C, Salvi A, Refe MC, Strusi AS, Danieli G: Synchronised therapy and high-dose cyclophosphamide in proliferative lupus nephritis. J Clin Apher 2002;17:72–77.
25.
Frankel AH, Singer DR, Winearls CG, Evans DJ, Rees AJ, Pusey CD: Type II essential mixed cryoglobulinaemia: presentation, treatment and outcome in 13 patients. Q J Med 1992;82:101–124.
26.
Berkman EM, Orlin JB: Use of plasmapheresis and partial plasma exchange in the management of patients with cryoglobulinemia. Transfusion 1980;20:171–178.
27.
Clark WF, Stewart AK, Rock GA, et al: Plasma exchange when myeloma presents as acute renal failure: a randomized, controlled trial. Ann Intern Med 2005;143:777–784.
28.
Leung N, Gertz MA, Zeldenrust SR, et al: Improvement of cast nephropathy with plasma exchange depends on the diagnosis and on reduction of serum free light chains. Kidney Int 2008;73:1282–1288.
29.
Hutchison CA, Bradwell AR, Cook M, et al: Treatment of acute renal failure secondary to multiple myeloma with chemotherapy and extended high cut-off hemodialysis. Clin J Am Soc Nephrol 2009;4:745–754.
30.
Rizzoni G, Claris-Appiani A, Edefonti A, et al: Plasma infusion for hemolytic-uremic syndrome in children: results of a multicenter controlled trial. J Pediatr 1988;112:284–290.
31.
Colic E, Dieperink H, Titlestad K, Tepel M: Management of an acute outbreak of diarrhoea-associated haemolytic uraemic syndrome with early plasma exchange in adults from southern Denmark: an observational study. Lancet 2011;378:1089–1093.
32.
Rock GA, Shumak KH, Buskard NA, et al: Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic purpura. Canadian Apheresis Study Group. N Engl J Med 1991;325:393–397.
33.
Michael M, Elliott EJ, Ridley GF, Hodson EM, Craig JC: Interventions for haemolytic uraemic syndrome and thrombotic thrombocytopenic purpura. Cochrane Database Syst Rev 2009:CD003595.
34.
Tobian AA, Shirey RS, Montgomery RA, et al: ABO antibody titer and risk of antibody-mediated rejection in ABO-incompatible renal transplantation. Am J Transplant 2010;10:1247–1253.
35.
Snanoudj R, Candon S, Legendre C: Targeting B cells in sensitized kidney transplant patients: state of the art and future perspectives. Curr Opin Organ Transplant 2010, E-pub ahead of print.
36.
White NB, Greenstein SM, Cantafio AW, et al: Successful rescue therapy with plasmapheresis and intravenous immunoglobulin for acute humoral renal transplant rejection. Transplantation 2004;78:772–774.
37.
Rocha PN, Butterly DW, Greenberg A, et al: Beneficial effect of plasmapheresis and intravenous immunoglobulin on renal allograft survival of patients with acute humoral rejection. Transplantation 2003;75:1490–1495.
38.
Stegall MD, Gloor J, Winters JL, Moore SB, Degoey S: A comparison of plasmapheresis versus high-dose IVIG desensitization in renal allograft recipients with high levels of donor specific alloantibody. Am J Transplant 2006;6:346–351.
39.
Higgins RM, Bevan DJ, Carey BS, et al: Prevention of hyperacute rejection by removal of antibodies to HLA immediately before renal transplantation. Lancet 1996;348:1208–1211.
40.
Salama AD, Delikouras A, Pusey CD, et al: Transplant accommodation in highly sensitized patients: a potential role for Bcl-xL and alloantibody. Am J Transplant 2001;1:260–269.
41.
Winters JL, Gloor JM, Pineda AA, Stegall MD, Moore SB: Plasma exchange conditioning for ABO-incompatible renal transplantation. J Clin Apher 2004;19:79–85.
42.
Sonnenday CJ, Warren DS, Cooper M, et al: Plasmapheresis, CMV hyperimmune globulin, and anti-CD20 allow ABO-incompatible renal transplantation without splenectomy. Am J Transplant 2004;4:1315–1322.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.