Ridel Christophe, Kissling Sébastien, Mesnard Laurent, Hertig Alexandre, Rondeau Éric
Service des urgences néphrologiques et transplantation rénale, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France; Université Pierre-et-Marie-Curie, 4, place Jussieu, 75005 Paris, France.
Service des urgences néphrologiques et transplantation rénale, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France; Université Pierre-et-Marie-Curie, 4, place Jussieu, 75005 Paris, France; Service de néphrologie et hypertension, centre hospitalier universitaire vaudois (CHUV), 21, rue du Bugnon, 1011 Lausanne, Suisse.
Nephrol Ther. 2017 Feb;13(1):43-55. doi: 10.1016/j.nephro.2016.12.002. Epub 2017 Jan 16.
Plasma exchange is a non-selective apheresis technique that can be performed by filtration or centrifugation allowing rapid purification of high molecular weight pathogens. An immunosuppressive treatment is generally associated to reduce the rebound effect of the purified substance. Substitution solutes such as human albumin and macromolecules are needed to compensate for plasma extraction. Compensation by viro-attenuated plasma is reserved solely for the treatment of thrombotic microangiopathies or when there is a risk of bleeding, because this product is very allergenic and expensive. The treatment goal for a plasma exchange session should be between one and one and one-half times the patient's plasma volume estimated at 40 mL/kg body weight. The anticoagulation is best ensured by the citrate. Complications of plasma exchange are quite rare according to the French hemapheresis registry. The level of evidence of efficacy of plasma exchange in nephrology varies from one pathology to another. Main indications of plasma exchange in nephrology are Goodpasture syndrome, antineutrophil cytoplasmic antibody vasculitis when plasma creatinine is greater than 500 μmol/L, and thrombotic microangiopathies. During renal transplantation, plasma exchange may be proposed in the context of human leukocyte antigen (HLA) desensitization protocols or ABO-incompatible graft. After renal transplantation, plasma exchange is indicated as part of the treatment of acute humoral rejection or recurrent focal segmental glomerulosclerosis on the graft. Plasma exchanges are also proposed in the management of cryoglobulinemia or polyarteritis nodosa. Hemodialysis with membranes of very high permeability tends to replace plasma exchange for myeloma nephropathy. The benefit from plasma exchange has not been formally demonstrated for the treatment of severe lupus or antiphospholipid antibody syndrome. There is no indication of plasma exchange in the treatment of scleroderma or nephrogenic systemic fibrosis. More selective apheresis techniques such as immunoadsorption are currently proposed to replace plasma exchange.
血浆置换是一种非选择性血液分离技术，可通过过滤或离心进行，能快速纯化高分子量病原体。通常会联合免疫抑制治疗以减轻纯化物质的反弹效应。需要用人白蛋白和大分子等置换溶质来补充血浆提取。仅在治疗血栓性微血管病或存在出血风险时才使用减毒病毒血浆进行补充，因为该产品具有很强的致敏性且价格昂贵。一次血浆置换治疗的目标量应为根据患者体重按40 mL/kg估算的血浆量的1至1.5倍。最好用枸橼酸盐确保抗凝。根据法国血液分离登记处的数据，血浆置换的并发症相当罕见。血浆置换在肾脏病学中的疗效证据水平因病理情况而异。血浆置换在肾脏病学中的主要适应证包括肺出血肾炎综合征、血浆肌酐大于500 μmol/L时的抗中性粒细胞胞浆抗体血管炎以及血栓性微血管病。在肾移植期间，在人类白细胞抗原（HLA）脱敏方案或ABO血型不相容移植的情况下可考虑进行血浆置换。肾移植后，血浆置换可作为急性体液排斥反应或移植肾复发性局灶节段性肾小球硬化治疗的一部分。血浆置换也用于冷球蛋白血症或结节性多动脉炎的治疗。具有很高通透性的膜进行血液透析往往会取代血浆置换用于治疗骨髓瘤肾病。血浆置换治疗重症狼疮或抗磷脂抗体综合征的益处尚未得到正式证实。硬皮病或肾源性系统性纤维化的治疗中没有血浆置换的适应证。目前有人提出用免疫吸附等更具选择性的血液分离技术来取代血浆置换。
