Therapeutic Plasma Exchange (TPE) is an extracorporeal therapy designed to remove large molecular weight substances from the plasma. Following the trials carried out and the recommendations of ASFA 2013, the role of TPE in nephropathy treatment has been undergone many revisions “Schwartz J-2013″ . In 2012 among the kidney diseases, the Canadian Apheresis Group reported TTP/ HUS as the main indication for TPE (63%); ANCA-associated vasculitides were 14%, followed by renal transplantation (10%), Goodpasture’s syndrome (6%) and FSGS post-transplantation (5%); cryoglobulinemia (2%) and nephropathy myeloma (<1%) instead experienced a drastic reduction of cases; no reports of SLE was reported “Clark WF-2012” . Recent clinical studies have focused on TPE effect towards rapidly progressive GN and hemorrhagic alveolitis “Vanhille P-2012 “, “Casian A-2011 “.
We reviewed 19 clinical records (10 males, 9 females) inside our department from 2004 to 2011. Each patient received TPE session every 24–48 h for 2 weeks, but more treatments were sometimes carried out (up to 26 treatments). We chose a double lumen catheter in the jugular or femoral vein for temporary vascular access and sodium citrate for anticoagulation. Except in HUS (fresh frozen plasma), we usually used albumin solution as replacement fluid. The exchanged plasma volume (2-2,5 L) was depending on the body weight of the patient and the hematocrit value, using the formula: plasma volume = body weight x 0.07 x [1- hematocrit]. We treated: 3 Wegener Granulomatosis, 4 reno-pulmonary ANCA-associated vasculitides, 3 HUS, 2 cast-nephropathy multiple myeloma, 1 crescentic GN with brain involvement, 2 crescentic GN alone, 2 SLE; 1 patient with membranoproliferative GN due to HCV-cryoglobulinemic vasculitis was treated in 2 different times with plasmapheresis. TPE treatments were always coupled with steroids and immunosuppressive therapy. All these cases were characterized by active bleeding (hemoptysis, metrorrhagia, epistaxis), severe dyspnea or rapid progression of renal failure without a favorable response to steroid treatment alone. In 4 cases we observed the complete resolution of symptoms and normalization of renal function; 7 patients improved their clinical status without an improvement in renal function; 5 patients improved both clinical status and renal function; 3 cases had a fatal outcome. No complications associated with TPE procedure were described. The 3 patients who died, were suffering from ANCA-positive vasculitis with severe brain and renal involvement, ANCA-positive vasculitis with pulmonary involvement and renal failure, sepsis with severe active bleeding (hematuria).
We believe that systemic involvement and late transfer to our department has made ineffective both drug therapy and TPE. The 5 subjects who gained a favor and complete result, younger than the other patients, were suffering from SLE (3 cases) and ANCA-positive vasculitis (2 cases). We believe that the timely transfer to our department and the rapid onset of both drug treatment and TPE, have successfully. produced a result. We plan to optimize the use of TPE and extend its use according to international guidelines.