Therapeutic Apheresis in Transplantation: Overview and Critical Evaluation of Available Modalities in Respect to Indications, Evidence and Costs

Transplantation is the organ replacement therapy of choice, but immunological problems like preformed donor-specific antibodies or a high degree of immunization complicate the outcome of deceased or living donor transplantation. Postoperatively additional problems can limit the therapeutic success of transplantation, e.g. antibody-mediated rejections or drug-related side effects of the medication like the calcineurin inhibitor-induced thrombotic microangiopathy. Therapeutic strategies include a primary avoidance of immunization, careful patient selection, a meticulous immunological workup and a proper follow-up. In the event of an antibody-mediated disease, therapeutic apheresis is a cornerstone of management. Several techniques are available, but each technique is characterized by specific advantages as well as disadvantages for particular clinical problems. Due to the considerable costs and based on these characteristics, a careful selection of the procedure is mandatory but often not easy to accomplish. This overview will describe indications for therapeutic apheresis in the field of transplantation, illustrate the application of the available techniques to these indications by patient case studies and will provide a critical evaluation of the available techniques for therapeutic apheresis in respect to indications, evidence and costs.