F – 05 – Plasma exchange
Plasma Exchange for Kidney Disease: What Is the Best Evidence?
Ainslie M. Hildebrand, Shih-Han S. Huang, William F. Clark
Advances in Chronic Kidney Disease
Volume 21, Issue 2 , Pages 217-227, March 2014
Address correspondence to William F. Clark, MD, Room A2-341 London Health Sciences
Centre, 800 Commissioners Road East, London, Ontario, Canada N6A 4G5.
ABSTRACT
Therapeutic plasma exchange (TPE) has been used as adjunctive therapy for various kidney
diseases dating back to the 1970s. In many cases, support for TPE was on mechanistic
grounds given the potential to remove unwanted large molecular-weight substances such as
autoantibodies, immune complexes, myeloma light chains, and cryoglobulins. More recently,
growing evidence from randomized controlled trials, meta-analyses, and prospective studies
has provided insights into more rational use of this therapy. This report describes the role of
TPE for the 6 most common kidney indications in the 2013 Canadian Apheresis Group
(CAG) registry and the evidence that underpins current recommendations and practice.
These kidney indications include thrombotic microangiopathy, antiglomerular basement
membrane
disease,
anti-neutrophil
cytoplasmic
antibody-associated
vasculitis,
cryoglobulinemia, recurrence of focal and segmental glomerulosclerosis in the kidney
allograft, and kidney transplantation.
Key Words: Plasma exchange, Kidney disease, Thrombotic microangiopathy, Vasculitis,
Kidney transplantation
COMMENTS
•The use of plasma exchange for kidney disease by the CAG correlates with published
evidence.
•Early introduction of plasma exchange appears to be effective for various immunologic
kidney diseases. However, plasma exchange primarily serves as an adjunct to other
immunosuppressive therapies and is often expected to offer only a small, incremental
benefit.
•The strongest evidence for plasma exchange is for thrombotic microangiopathy, in which it
serves as the single most important therapy in most cases.
Therapeutic plasma exchange (TPE) is an automated extracorporeal apheresis technique in
which plasma and large molecular-weight substances are removed from the body through a
cell separator and replaced with another blood product such as donor plasma or albumin.
The introduction of TPE as a form of treatment for kidney disease was initially reported by
Lockwood and colleagues in 1975 in a patient who suffered from Goodpasture's syndrome.
Treatment with TPE in combination with immunosuppressive therapy resulted in recovery
from kidney failure and pulmonary hemorrhage. Since then, TPE has been used in various
kidney diseases directed primarily at 2 main mechanisms: (1) removal of unwanted large
molecular-weight substances, such as autoantibodies, immune complexes, myeloma light
chains, and cryoglobulins; and (2) replacement of deficient substances, such as ADAMTS13
(A Disintegrin And Metalloprotease with a ThromboSpondin type 1 motif, member 13) in the
case of thrombotic thrombocytopenic purpura (TTP).
The kidney indications include thrombotic microangiopathy (TMA), anti-GBM disease, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, cryoglobulinemia, recurrence
of focal and segmental glomerulosclerosis in the kidney allograft, and kidney transplantation.