Therapeutic Apheresis in Immunologic Renal and Neurological Diseases

Abstract

Since the mid 1970s, when membrane modules became available, plasma separation techniques have gained in importance especially in the past few years. The advantages of this method are a complete separation of the corpuscular components from the plasma and due to increased blood flow rate and higher efficacy. Systemic autoimmune diseases based on an immune pathogenesis produce autoantibodies and circulating immune complexes, which cause inflammation in the tissues of various organs. In most cases, these diseases have a poor prognosis without treatment. Therapeutic apheresis (TA) in combination with immunosuppressive therapies has led to a steady increase in survival rates over the last 40 years. The updated information on immunology and molecular biology of different immunologic 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 such as therapeutic plasma exchange (TPE) with substitution solution, or with online plasma or blood purification using adsorption columns, which contain biological or non-biological agents. Here, the authors provide an overview of the most important pathogenic aspects indicating that TA can be a supportive therapy in systemic autoimmune diseases such as renal and neurological disorders. For the immunological diseases that can be treated with TA, the guidelines of the German Working Group of Clinical Nephrology and of the Apheresis Committee of the American Society for Apheresis are cited.

Capsid-specific removal of circulating antibodies to adeno-associated virus vectors

“…Critical parameters, like the optimal quantity of capsid antigen required to efficiently capture anti-AAV Ig, will also need to be defined. Furthermore, it would be useful to identify protocols in which the current technology is combined with an immunomodulatory regimen to increase the efficiency of the approach and thus achieve clearance of anti-AAV antibodies more rapidly than with plasmapheresis alone 45 . While the current proof-of-concept work demonstrated the feasibility of the approach in the context of one specific serotype, the development of column containing multiple AAV serotypes, therefore with different specificities, could potentially represent a universal device for antibodies directed to different AAVs.…”

Reflections

“…In parallel, efforts are underway to develop improved dialytic technology. In some nephrological diseases, the etiology is autoimmune or immunologically related, 2,25 such as rapidly progressing glomerulonephritis, Goodpasture's, Henoch‐Schӧnlein purpura nephritis, focal segmental glomerulosclerosis, crescentric nephritis, lupus nephritis, ANCA‐associated glomerulonephritis, immune complex nephritis, and transplantation rejection. Efforts to preserve kidney function are critical to avoid end‐stage disease.…”

Therapeutic Apheresis in Hematologic, Autoimmune and Dermatologic Diseases With Immunologic Origin

“…Therapeutic plasma exchange is indicated in the management of various hematological diseases. For most of these diseases, clear pathogenetic mechanisms of the disease are understood, and there are well‐defined criteria with regard to the therapy . Most medical management of immunohematological disorders requires the use of TA, serological immunomodulation, and classical pharmacological immunosuppression with steroids, cytotoxic agents, and antimetabolites, where overall therapy is individually tailored to the needs of the patient.…”