Therapeutic Apheresis Medicine: Helpful Practical Advice at Your Fingertips

The practice of apheresis medicine, particularly in its use as therapy for specific conditions, is a burgeoning multidisciplinary field in which nephrologists in the United States and elsewhere are directly involved. Very often, a request comes from a different clinical service to use therapeutic apheresis as part of the treatment for specific conditions. At such times, the question “to treat or not to treat” arises because many factors need to be considered for a well-informed decision. Some of them include the following important questions: Is the disease or condition in the patient amenable to treatment with apheresis? If so, do the risks versus the benefits favor apheresis?

A great addition to the scholarly material available to help with this decision-making process has been coming from the American Society for Apheresis (ASFA) since 1986, the year of the publication of the first of a series of systematic reviews of therapeutic apheresis applications. These recommendations were revised every 7 years initially and, since 2007, every 3 years. The final product, also termed the Special Issue of the Journal of Clinical Apheresis or, more informally and more recently, the “ASFA guidelines,” also addresses those dilemmas and helps clinicians make informed decisions. The past three special issues have been restructured to use an evidence-based approach.

The guidelines are composed of page-long fact sheets for each disease, including specific clinical presentations within each disease. At the top of the page, the role of therapeutic apheresis is categorized from I to IV (Table 1 and 2) and with the strength of the recommendation that is based on the quality of the most recent published evidence. The standardized format—a one-page fact sheet—allows for concise but comprehensive data to be presented, along with the references used to prepare the guidelines.

Table 1
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Table 2
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The sixth edition of the ASFA guidelines was published in the summer of 2013 (1). This current edition is the most comprehensive to date, encompassing 78 diseases or conditions, listed in alphabetic order from acute disseminated encephalomyelitis to Wilson disease. Table 2 includes all diagnoses considered to be category I indications for the various types of therapeutic apheresis. The ASFA guidelines have been used in the United States and beyond (translations to other languages exist) to help in the decision to treat or not to treat with therapeutic apheresis and, if so, how to appropriately perform the procedure (such as replacement fluid in therapeutic plasma exchange and number of plasma-volumes exchanged) and monitor the patient while protecting the patient’s safety and ensuring the quality of the therapeutic apheresis care delivered.

Reference

1

Schwartz J, et al. Guidelines on the use of therapeutic apheresis in clinical practice—evidence-based approach from the Writing Committee of the American Society for Apheresis: the sixth special issue. J Clin Apher 2013; 28:145–284.