Double Filtration Plasmapheresis in Antibody‐Incompatible Kidney Transplantation

Abstract

Double filtration plasmapheresis (DFPP) was used in preference to plasma exchange in our program of antibody-incompatible transplantation, to treat higher volumes of plasma. Forty-two patients had 259 sessions of DFPP, 201 pre-transplant and 58 post-transplant. At the first treatment session, the mean plasma volume treated was 3.81 L (range 3-6 L), 55.5 mL/kg (range 36.2-83.6 mL/kg). Serum IgG fell by mean 59.4% (SD 10.2%), and IgM by 69.3% (SD 16.1%). Nine patients did not require increases in plasma volumes treated, and six did not tolerate higher plasma volumes. In the remaining patients, the mean maximum plasma volume treated pre-transplant was 6.67 L (range 4-15 L), 96.1 mL/kg (range 60.2-208.9 mL/kg). The complement dependent cytotoxic crossmatch was positive in 14 cases pre-treatment, and remained positive in six (42.8%) cases. The flow cytometric crossmatch was positive in 29 cases pre-treatment, and in 21 (72.4%) after DFPP. Post-transplant, DFPP was ineffective at reducing donor specific antibody levels during periods of rapid donor specific antibody synthesis. Post-transplant, the one year graft survival rate was 94%, although there was a high rate of early rejection. In summary, DFPP enabled the treatment of plasma volumes that were almost double those that would have been feasible with plasma exchange. Despite this, most patients were transplanted with a positive crossmatch, and DFPP post-transplant was unable to control rising antibody levels.

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“…9 We used double-filtration plasmapheresis because this is a safe and effective method, no coagulation factors are eliminated, and large plasma volumes may be passed. 10 In the present study, double-filtration plasmapheresis was effective at decreasing the ABO antibody titer (immunoglobulin G) before transplant. When the recipient's blood group antibody titer was low, no pretransplant antibody-reducing regimen was used, and this approach has been effective.…”

ABO-incompatible kidney transplantation

“…For selective immunoglobulin removal, two options are available: after plasma separation, immunoglobulins can be filtered semi-selectively (so-called 'double filtration plasmapheresis' [15]), or they can be adsorbed in columns coated with protein A (binding mainly IgG) or sheep antihuman immunoglobulin (binding most antibody isotypes). These techniques allow treating higher plasma volumes and lead to a dramatic IgG depletion.…”

Role of therapeutic plasmapheresis in ANCA-associated vasculitis

“…This reduces cellular loss and maximizes the efficiency of plasma removal [16]. Double-filtration plasmapheresis [17] aims to reduce the loss of the lower molecular weight molecules otherwise lost in the filtration process, returning them to the patient. Other methods have been tried, the earliest of which was electrodialysis in which the blood was passed through an electric field that drew the negatively charged larger molecules to one side, from where they were withdrawn.…”