Therapeutic Apheresis and Immunosuppression in Renal Diseases

Therapeutic plasma exchange (TPE) with hollow fiber modules is used in different severe diseases since more than 40 years. The authors try to give an overview of therapeutic apheresis (TA) in renal diseases. The updated information on immunology and molecular biology of different renal diseases are discussed in relation to the rationale for apheresis therapy and its place in combination with other modern treatments. The different renal diseases can be treated by various apheresis methods such as TPE with substitution solution, or with online plasma or blood purification using adsorption columns, which contain biological or non-biological agents. The following diseases are discussed: rapidly progressive glomerulonephritis (RPGN) including anti-glomerular basement membrane antibody glomerulonephritis (anti-GBM RPGN), RPGN with or without glomerular deposition (ANCA-ab), pauci-immune RPGN, immune complex nephritis (ICN), and various glomerulonephritis with nephrotic syndrome (NS), acute kidney injury (AKI), myoglobulinemic renal failure, hemolytic-uremic syndrome (HUS), and kidney transplant rejection. For the renal diseases, which can be treated with TA, the guidelines of the Apheresis Applications Committee (AAC) of the American Society for Apheresis (ASFA) are shown.

Therapeutic Apheresis in Neurology

Therapeutic plasma exchange (TPE) remove harmful plasma constituents from patient’s blood and replacing the extracted plasma with replacement solutions. The advantages of TPE with hollow fiber membranes are a complete separation of the corpuscular components from the plasma and due to increased blood flow rate higher efficacy. Therapeutic apheresis (TA) is used more and more throughout the world. The development of new, more sophisticated membranes and new adsorption technologies allow the most selective separation of plasma components. TA has been successfully introduced in a variety of autoantibody-mediated diseases. TA is the first- or second-line therapy in the treatment of neurological disorders. The updated information on immunology and molecular biology of different neurological diseases are discussed in relation to the rationale for apheresis therapy and its place in combination with other modern treatments. The different neurological diseases can be treated by various apheresis methods. Pathogenetical aspects are demonstrated in these diseases, in which they are clarified. TA has been shown to effectively remove the autoantibodies, immune complexes, inflammatory moderators, paraproteins, and other toxins from blood and lead to rapid clinical improvement. For the neurological diseases, which can be treated with TA, the guidelines of the Apheresis Application Committee (AAC) of the American Society for Apheresis (ASFA) are cited.

Why Some Patients Undergoing Lipoprotein Apheresis Therapy Develop New Cardiovascular Events?

Lipoprotein apheresis (LA) is an effective tool to reduce cardiovascular events (CVEs) in high-risk patients with elevations of low density lipoprotein-cholesterol (LDL-C) and/or Lipoprotein(a) (Lp(a)). All patients included into this retrospective analysis had experienced CVEs before the start of the LA therapy. We compared personal and lab data in two groups: CVEx/0 (n 60) with no new events during LA therapy, CVEx/1+ (n 48) with at least one new event. Patients of Group CVEx/1+ were about 5 years older when they had started the extracorporeal therapy, and they experienced more CVEs prior to that timepoint. There was a positive correlation between the number of CVEs before and during LA therapy. No differences were seen with respect to lipid concentrations, even after a correction of LDL-C concentrations for the LDL-C transported with Lp(a) particles. LA sessions effectively reduced both LDL-C and Lp(a). Lp(a) levels measured before LA sessions were lower than those measured initially. It appeared difficult to reach the target values for LDL-C published in the ESC/EAS Guideline in 2019, although all patients were maximally treated including drugs when tolerated. In conclusion, it will be important to initiate an LA therapy earlier, at least after a second CVE and at a younger age.

Therapeutic Apheresis in Pediatrics with Neurological and Hematological Diseases

The advantages of therapeutic apheresis (TA) with hollow fiber membranes are a complete separation of the corpuscular components from the plasma and due to increased blood flow rate higher efficacy [1]. The use of therapeutic apheresis in pediatric patients, which increasing more and more, has always been restricted by technical difficulties and the low incidence of diseases requiring this kind of treatment. The development of new, more sophisticated membranes and new adsorption technologies allow the most selective separation of plasma components. TA has been successfully introduced in a variety of autoantibody-mediated diseases [2]. The updated information on immunology and molecular biology of different neurological and hematological diseases are discussed in relation to the rationale for apheresis therapy and its place in combination with other modern treatments. The different diseases can be treated by various apheresis methods. Pathogenetical aspects are demonstrated in these diseases, in which they are clarified. TA has been shown to effectively remove the autoantibodies from blood and lead to rapid clinical improvement. For the neurological and hematological diseases, which can be treated with TA, the guidelines of the Apheresis Application Committee (AAC) of the American Society for Apheresis (ASFA) are cited [3, 4].

Dual-chambered venous access port as alternative access for extracorporeal apheresis therapy

Purpose: To evaluate the use of a dual-chambered venous access port for extracorporeal apheresis therapy. Methods: This was a single-center retrospective analysis of all patients who received a dual-chambered venous access port for apheresis therapy over a 36-month period. Clinical success was defined as successful completion of at least one round of apheresis via the venous access port. Major complications were defined as any event requiring elevation of patient care and/or venous access port removal or repositioning. Minor complications were defined as venous access port issues resolved with clinical intervention. Results: Forty-four patients had a venous access port placed at the time of this study. Patients underwent red cell exchange (n = 33), therapeutic plasma exchange (n = 6) or extracorporeal photopheresis (n = 5). Forty (90%) patients had autoimmune diseases and four (10%) had neoplastic processes. Clinical success was achieved in 42 (95.5%) patients. Average venous access port dwell time was 632 days (range = 42–1191 days). All therapies through the venous access ports were well tolerated and no patients reported pain or discomfort. Major complications were seen in nine (20.5%) patients–the majority (n = 7) of which were due to venous access port malfunction–and resolved with catheter revision. One (2.27%) major complication involved an infected venous access port, and one involved a large hematoma at the venous access port site. Minor complications were seen in eight (18.2%) patients, where simple flushing of the catheter with saline or tissue plasminogen activator resolved the issue. Conclusion: The dual-chambered venous access port was successfully used for sustained blood flow in apheresis therapy with a moderate, yet correctable complication rate.

Extracorporeal Immunotherapy in Oncology

Tumors development is closely related to the immune system state and in immunosuppression tumors occur many times more often. The quality of the immune defense depends on how the recognition system functions for malignized tumor cells and its timely destruction. However, the immunosuppression state may be a result of the tumor process itself. The tumor itself generates soluble molecules that inhibit the killer activity of lymphocytes and macrophages, which allows tumor cells to survive in the body. Therefore, it is justified to perform apheresis therapy aimed at removal of such inhibitors, and targeted restoration of cytotoxic activity of leukocytes, which should contribute to the tumor cells apoptosis. This method of extracorporeal immunopharmacotherapy is indicated not only in far-advanced cases, but also after any radical operations, when metastases are not detected and even chemotherapy is not carried out.