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[Plasma exchange in nephrology: Indications and technique].

Christophe Ridel1, Sébastien Kissling2, Laurent Mesnard1

  • 1Service des urgences néphrologiques et transplantation rénale, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France; Université Pierre-et-Marie-Curie, 4, place Jussieu, 75005 Paris, France.

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Summary

Plasma exchange rapidly removes harmful substances but requires immunosuppression and volume replacement. Its efficacy in nephrology varies, with key uses in specific autoimmune diseases and transplantation, while newer methods emerge.

Keywords:
ApheresisAphérèseImmunoadsorptionImmunoadsorption therapyPlasmaPlasma exchangeSoluté de substitutionSubstitution soluteÉchange plasmatique

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Area of Science:

  • Nephrology
  • Apheresis Techniques
  • Immunology

Background:

  • Plasma exchange is a non-selective apheresis method for removing high molecular weight pathogens.
  • It necessitates immunosuppression to prevent rebound and volume replacement with solutes like albumin.
  • Viro-attenuated plasma is used cautiously due to cost and allergenicity, primarily for thrombotic microangiopathies.

Purpose of the Study:

  • To review the indications and efficacy of plasma exchange in nephrology.
  • To discuss its role in various renal diseases and transplantation scenarios.
  • To compare plasma exchange with alternative apheresis techniques.

Main Methods:

  • Review of plasma exchange principles, including filtration/centrifugation, anticoagulation (citrate), and volume goals (1-1.5 plasma volumes).
  • Analysis of complication rates from registries, noting they are generally rare.
  • Evaluation of evidence levels for plasma exchange efficacy across different nephrological conditions.

Main Results:

  • Key indications include Goodpasture syndrome, ANCA vasculitis (>500 μmol/L creatinine), and thrombotic microangiopathies.
  • In transplantation, it's used for HLA desensitization, ABO-incompatible grafts, acute humoral rejection, and recurrent FSGS.
  • Hemodialysis and immunoadsorption are emerging alternatives for specific conditions like myeloma nephropathy.

Conclusions:

  • Plasma exchange has established roles in specific nephrological conditions and post-transplant management.
  • Its benefit is not proven for lupus or antiphospholipid antibody syndrome, and it's not indicated for scleroderma or NSF.
  • Selective apheresis techniques like immunoadsorption are increasingly preferred over plasma exchange.