Plasmapheresis in nephrology: an update

Abstract

In the past, recommendations for the use of plasmapheresis were based on findings reported from pilot studies or anecdotes. New results from several randomized controlled trials have changed the indications for the use of plasma exchange. A large randomized controlled study of patients with antineutrophil cytoplasmic antibody associated vasculitis showed benefit of plasmapheresis in those with severe renal disease. Patients receiving plasmapheresis compared with methylprednisolone as adjuvant therapy were more likely to be alive and dialysis independent. Plasmapheresis, following publication of a recent randomized controlled trial, should no longer be used for patients with myeloma and acute renal failure. Standard therapy with five to seven plasma exchanges was compared with standard therapy alone. There was no difference in those patients reaching the composite endpoints between the two treatments. New indications include desensitization protocols, using plasmapheresis and intravenous immunoglobulin, which have allowed transplantation across immunological barriers. Highly sensitized patents and ABO incompatible patients compared with their potential donors are now being transplanted with excellent results. Studies still need to be done to assess the best desensitization protocol. The use of plasmapheresis requires further validation by randomized clinical trials. Recent published trials should alter practice but further studies are required.