From the Guidelines
Pulmonary hemorrhage without kidney involvement is not an indication for Therapeutic Plasma Exchange (Plasmapheresis).
Indications for Plasmapheresis
- The evidence suggests that plasmapheresis is recommended for patients with severe kidney impairment, such as those with serum creatinine ≥500 μmol/L 1 or rapidly progressive severe renal disease 1.
- It is also recommended for patients with an overlap syndrome of ANCA vasculitis and anti-GBM disease 1.
- However, for patients with pulmonary hemorrhage without kidney involvement, the evidence suggests that immunosuppression alone without plasma exchange is recommended 1.
Details of the Evidence
- A clinical practice guideline published in the BMJ in 2022 recommends against plasma exchange in patients with AAV and pulmonary hemorrhage without kidney involvement 1.
- The EULAR recommendations for the management of ANCA-associated vasculitis, published in 2024, state that routine use of plasma exchange to treat alveolar hemorrhage in GPA and MPA is not recommended 1.
- These guidelines are based on the lack of evidence to support the use of plasma exchange in these patients, and the potential harms of the treatment, such as serious infections 1.
From the Research
Conditions Not Indicated for Therapeutic Plasma Exchange
- Rheumatoid arthritis, as stated in 2, where controlled clinical trials did not find therapeutic benefit of plasma exchange.
- Systemic lupus erythematosus, as mentioned in 2, where plasma exchange therapy was not found to be beneficial by controlled clinical trials.
- Polymyositis, as indicated in 2, where therapeutic benefit of plasma exchange was not found by controlled clinical trials.
- Dermatomyositis, as stated in 2, where controlled clinical trials did not find therapeutic benefit of plasma exchange.
- Multiple sclerosis, although some studies like 3 suggest plasma exchange therapy can be effective in steroid-unresponsive relapses, the general indication is not strongly supported as in other conditions like vasculitis or TTP.
- Rejection of kidney allotransplant, as mentioned in 2, where therapeutic benefit of plasma exchange was not found by controlled clinical trials.
Conditions with Limited or No Clear Indication for Therapeutic Plasma Exchange
- ANCA-related vasculitis, where recent RCTs have shown negative results regarding the efficacy of plasma exchange in reducing mortality and renal death, as discussed in 4.
- Some forms of small vessel vasculitis, where the recommendation for plasma exchange seems to be high for immune complex vasculitis but less clear for others, as mentioned in 4.