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Updated: Jun 8, 2025
Murine Kidney Transplant Technique
Published on: October 20, 2015
Therapeutic Apheresis in Pediatric Renal Transplant Recipients
1From the Urology and Nephrology Research Center, Shahidbeheshti of Medical Sciences, Tehran, Iran.
Insights
Therapeutic apheresis shows promise for pediatric renal transplant recipients, effectively managing conditions like antibody-mediated rejection and focal segmental glomerulosclerosis when combined with immunosuppression. While complications exist, it offers a valuable treatment option.
Area of Science:
- Nephrology
- Immunology
- Pediatric Medicine
Background:
- Clear guidelines for therapeutic apheresis in pediatric renal transplant recipients are lacking.
- Therapeutic apheresis involves removing specific substances from the blood to treat diseases.
- Understanding the characteristics of removable substances is key to effective apheresis.
Purpose of the Study:
- To review current experiences and effectiveness of therapeutic apheresis in pediatric renal transplant recipients.
- To discuss the mechanisms and modalities of therapeutic apheresis.
- To highlight its role in managing specific post-transplant complications.
Main Methods:
- Review of current literature and experiences with therapeutic apheresis in pediatric transplant recipients.
- Analysis of ideal characteristics for removable substances (e.g., molecular weight, half-life).
- Discussion of various apheresis modalities including plasmapheresis, immunoadsorption, and photopheresis.
Main Results:
- Therapeutic apheresis is effective for post-transplant nephrotic syndrome (focal segmental glomerulosclerosis), atypical hemolytic uremic syndrome (66% remission), and chronic antibody-mediated rejection (75% response).
- Immunoglobulin M and G removal requires different apheresis strategies due to their distribution and half-life.
- Apheresis also has immunomodulatory effects, increasing T-regulatory cells.
Conclusions:
- Therapeutic apheresis, particularly when combined with immunosuppressive drugs, is an effective tool for managing antibody-mediated rejection, focal segmental glomerulosclerosis, and atypical hemolytic uremic syndrome in pediatric renal transplant recipients.
- While potential complications exist, apheresis offers significant benefits for specific conditions.
- Further research and clear guidelines are needed to optimize its use in this population.
Abstract:
Clear guidelines for therapeutic apheresis in children after renal transplant do not exist. This article reviews the current experiences with therapeutic apheresis in pediatric transplant recipients. The ideal characteristics of removable substances should have all of the following criteria for an effective therapeutic apheresis: large molecular weight (>15 kDa), prolonged half-life, rapid elimination from the plasma, high intravascular distribution, and low turnover rate. Among these molecules, immunoglobulin M is ~75% intravascular; thus, only 1 or 2 therapeutic apheresis procedures are needed to reduce immunoglobulin M levels efficiently. In contrast, immunoglobulin G is distributed 45% intravascularly and returns to ~60% of preapheresis level within 48 hours; thus, the regimen involves 5 procedures and immunosuppressive therapy is crucial to reduce immunoglobulin G levels. Therapeutic apheresis can also remove cytokines. Immunomodulatory effects of therapeutic apheresis do not only remove unwanted substances but involve other important mechanisms, including increased T-regulatory cells compared with T-effector cells. Many modalities of therapeutic apheresis are used for pediatric transplant recipients, including plasmapheresis, double filtration plasmapheresis, photopheresis, lipopheresis, and immunoadsorption, which is the most effective but has a high cost. Therapeutic apheresis in pediatric transplant recipients is effective for posttransplant nephrotic syndrome (mainly focal segmental glomerulosclerosis). Therapeutic apheresis has also resulted in partial or complete remission for 66% of patients with atypical hemolytic uremic syndrome and 75% response rate for chronic antibody-mediated rejection. However, therapeutic apheresis should be accompanied by other immunosuppressive drugs to prevent rebound phenomena. Potential complications of therapeutic apheresis in pediatric transplant recipients include fluid and electrolyte imbalances, infection, bleeding, and reactions to replacement fluids during therapeutic apheresis. However, therapeutic apheresis (combined with immunosuppression) is an effective tool in most pediatric renal transplant recipients for management of antibody-mediated rejection, focal segmental glomerulosclerosis, and atypical hemolytic uremic syndrome.
