Table 3.
Therapeutic apheresis for the treatment of kidney diseases: recommendation grades and indication categories in 2019 American Society for Apheresis guidelines [1].
ABO incompatibleII
| Disease | Indication | Apheresis | Category | Recommendation grade | Technical notes |
|---|---|---|---|---|---|
| FSGS | Recurrent in KT | PE/IAS | I | Grade 1B | Volume treated: TPE, LA, or IA with single use adsorbers: 1.0–1.5 TPV; IA with regenerative adsorbers: 2–3 TPV.Frequency: Daily or every other day at initiation of treatment. Subsequent frequency and duration based on patient response. |
| Recurrent in KT/Steroid resistant in native kidney | LDL-A | II | Grade 2C | ||
| Steroid resistant in native kidney | PE | III | Grade 2C | ||
| Anti-GBM glomerulonephritis | DAH | PE | I | Grade 1C | Volume treated: 1–1.5 TPVFrequency: daily or every other day for 14 days or until anti-GBM undetectable |
| Dialysis-independence | PE | I | Grade 1B | ||
| Dialysis-dependence (Cr > 5.7mg/dl) | PE | III | Grade 2B | ||
| ANCA-associated disease | MPA/GPA/RLV | Volume treated: 1–1.5 TPVFrequency: daily in DAH, typically every other day in absence of DAH | |||
| RPGN, Cr ≥ 5.7mg/dl | PE | II | Grade 1B | ||
| RPGN, Cr < 5.7 mg/dl | PE | IIII | Grade 2C | ||
| DAH | PE | I | Grade 1C | ||
| EGPA | PE | III | Grade 2C | ||
| SLE | Severe complications | PE | II | Grade 2C | Volume treated: 1–1.5 TPVFrequency: LN or DAH: daily or every other day; Other severe complications: 1–3 times per week. Typically course of 3–6 PE is enough to see response |
| TMA | TTP | PE | I | Grade 1A | Volume treated: 1–1.5 TPVFrequency: daily until platelets >150K and LDH near normal for 2–3 consecutive days, taper vs abrupt discontinuation practices vary |
| STEC-HUS | PE/IAS | III | Grade 2C | Volume treated: 1–1.5 TPVFrequency: daily until improvement, no standardized approach exists | |
| aHUS | Volume treated: 1–1.5 TPVFrequency: daily until clinical response (complement mediated), daily or every other day for coagulation mediated TMA | ||||
| Factor H autoantibody | PE | I | Grade 2C | ||
| CF gene mutations | PE | III | Grade 2C | ||
| KT | |||||
| ABO incompatible | Desensitization | PE/IAS | I | Grade 1B | Volume treated: 1 - 1.5 TPV Frequency: daily or every other day. antibody titer is less than critical threshold prior to before KT |
| AMR | PE/IAS | II | Grade 1B | ||
| ABO compatible | Desensitization | PE/IAS | I | Grade 1B | Volume treated: 1–1.5 TPVFrequency: usually 5 or 6, daily or every other day |
| AMR | PE/IAS | I | Grade 1B |
FSGS: Focal segmental glomerulosclerosis; KT: kidney transplantation; PE: plasma exchange; IAS: immunoadsorption; LDL-A: low-density lipoprotein apheresis; GBM: glomerular basement membrane; DAH: diffuse alveolar hemorrhage; ANCA: antineutrophil cytoplasmic antibodies; MPA: microscopic polyangiitis; GPA: granulomatosis with polyangiitis; RLV: renal-limited vasculitis; EGPA: eosinophilic granulomatosis with polyangiitis; RPGN: rapidly progressive glomerulonephritis; SLE: systemic lupus erythematosus; TMA: thrombotic microangiopathy; TTP: thrombotic thrombocytopenic purpura; STEC-HUS: shiga toxin-mediated hemolytic syndrome; aHUS: atypical hemolytic uremic syndrome; CF: complement factor; AMR: antibody-mediated rejection; TPV: total plasma volume.