The most comprehensive guideline for the use of therapeutic apheresis is published by American society of Apheresis

The most comprehensive guideline for the use of therapeutic apheresis is published by American society of Apheresis (ASFA). It is fallen into four categories.
Category I includes disorders for which apheresis is accepted as first line of therapy
Category II includes diseases for which apheresis is accepted a second line therapy. category III includes entities for which the optimal role of apheresis is not established. category III includes disorders in which apheresis is reported ineffective or harmful. 1
Anti neutrophil cytoplasmic antibody (ANCA) associated vasculitis
These patients have a small vessel vasculitis often affecting the kidney, with pauci-immune precipitation.
This group of diseases includes granulomatosis with polyangitis (previously wegner granulomatosis) microscopic polyangitis and eosinophilic granulomatosis with polyangitis (previously churg – strauss syndrome). In 1977 lock wood et al. published the first report demonstrated the use of plasmapheresis in 9 patients with crescentic glomerulonephritis (GN), which 5 rapidly recovered kidney failure.2
Then, in 1991, pusy et al published a randomized control trial (RCY) that showed a benefit of plasmapheresis together with immunosuppressive drugs in ANCA associated vasculitis often requiring dialysis. A large European multicenter study (MEPEX) confirmed this finding and demonstrated in patients with a creatinine of > 500 mcmol/L (5.7 mg/dl) better recovery of renal function those treated with plasmapheresis compared to patients treated with pulse methylprednisolone. 2
TTP and HUS
Both TTP and HUS lead to thrombotic microangiopathy which in HUS especially affects the kidney and in TTP often involves the central nervous system
In TTP, there may be genetic deficiency of the von willebrand factor- cleaving protease (ADAMTS13) or autoantibodies against it. plasmapheresis will replace normal plasma components, regardless of etiology and will remove autoanti bodies when present. 3,4
In 1991, the Canadian apheresis groups definitively randomized controlled trial demonstrated the superiority of plasma exchange over plasma infusion for treating TTP patients. 4
In diarrhea negative (D-) HUS (atypical HUS) there are no controlled trials but there are several reports of the benefit of plasma exchange for FFP in severely affected patients. 4
Diarrhea positive (D+) HUS in children is usually a self limiting disease but there are recent reports of the benefit of plasmapheresis in adults with severe acute D+ HUS. 5
Recently, Eculizumab (a monoclonal antibody against C5 that inhibits the formation of the membrane attack complex of complement) is used to treat (D-) HUS and results have been very encouraging. 4
Cryoglobulinemia
Plasmapheresis has been used for the treatment of cryoglobalinemia for over 20 years and there are a lot of antibodys and complements that precipitate when exposed to cold temperature.
There are no controlled trials , but there are multiple reports established the efficacy of plasma exchange in patients with acute vasculitis and renal involvement. 4
Anti GBM disease (Good pastures)
Evidence of the pathogenicity of anti GBM antibodies are convinced, that the anti GBM disease was rapidly fatal in untreated patients
In the largest long term study using plasmapheresis together with immunosuppressive, almost all patients with creatinine< 200mol/L (5.7mg/dl) recovered renal . 6
Recurrent focal segmental glomerulosclerosis (FSGS)
Recurrent FSGS in renal transplant appears to be mediated in some cases by circulating factor that increases glomerular permeability
FSGS can recur promptly following renal transplantation (15%-55)and in the patient plasmapheresis is frequently reported to be of benefit but FSGS in the native kidney has variable results.7,8
Renal transplantation
Plasmapheresis has been used for over 20 years for treating antibody mediated rejection and recently, this has been used for desensitization Protocol for ABO in compatible or highly sensitized patients. 4
These were six disorders which have indicated plasmapheresis for first line or second line therapy in ASFA category.
There are several mechanisms by which plasmapheresis has beneficial effects for renal diseases including immunomodulatory actions and therapeutic actions.9

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