Therapeutische Apherese – Eine Übersicht aktueller Indikationsstellungen

Die therapeutische Apherese (TA) wurde erstmals 1914 für die Trennung des Plasmas von Erythrozyten (Plasmapherese) beschrieben. Zu den ersten Indikationen der TA bei Patienten vor ungefähr 50 Jahren gehörten die Behandlung der Paraproteinämie (M. Waldenström) und die Depletion von Leukämiezellen bei chronisch myeloischer Leukämie (CML) oder chronisch lymphatischer Leukämie (CLL). Die therapeutische Zelldepletion wird auch bei schwerer Polyzythämie oder Thrombozythämie bei myeloproliferativen Erkankungen, die gegenüber Medikamenten therapierefraktär und für den Patienten symptomatisch sind, eingesetzt. Ein Erythrozytenaustausch wird hingegen bei Erkrankungen der Erythrozyten, z. B. bei schweren Verlaufsformen der Malaria oder der Sichelzellanämien durchgeführt. Entsprechend den aktuell gültigen international anerkannten Guidelines der amerikanischen Gesellschaft für Apherese (6. Auflage, 2013), werden als Kategorie-I-Indikationen diejenigen Erkrankungen beschrieben, für die TA als Erstlinienbehandlung anerkannt ist und dabei entweder als alleinige Therapie oder in Verbindung mit anderen Behandlungsmodalitäten durchgeführt wird. Technisch unterscheidet man verschiedene Verfahren der TA. Selektive Verfahren können spezielle Proteine (z. B. Immunglobuline) durch Säulentechnik gezielt unter Verwendung spezieller immunologischer oder physikochemischer Verfahren entfernen. Bei progredienter kardiovaskulärer Erkrankung durch eine familiäre Hyperlipoproteinämie sind selektive TA, wie die Lipoproteinapherese, heute das einzige effiziente Therapieverfahren. Während nicht-selektive Verfahren (z. B. Plasmaaustausch, Zelldepletion) auch gesunde Blutkomponenten während der TA entfernen, die anschließend ersetzt werden müssen.

Therapeutic apheresis (TA) was first described in 1914 for the separation of plasma from erythrocytes (plasmapheresis). Among the first indications for TA in patients about 50 years ago were the treatment of paraproteinemia (Waldenström's disease) and thee depletion of leukemia cells in cases of chronic myeloid leukemia (CML) or chronic lymphatic leukemia (CLL). Therapeutic cell depletion is also employed for severe polycythemia or thrombocythemia in myeloproliferative diseases which are refractory to drug treatment and symptomatic for the patients. An erythrocyte exchange, on the other hand, is performed for diseases of erythrocytes, e. g., for severe forms of malaria or sickle cell anemia. According to the currently valid and internationally recognized guidelines of the American Society for Apheresis (6th edition, 2013)), category I indications are considered to be those diseases for which TA is established as a first-line treatment that is performed as monotherapy or in combination with other treatment modalities. Technically, we distinguish between various procedures for TA. Selective procedures can specifically remove special proteins (e. g., immunoglobulins) by column technologies using special immunological of physicochemical processes. In cases of progressive cardiovascular diseases, a selective TA such as lipoprotein apheresis, is today the only available efficient therapeutic procedure. However, non-selective procedures (e. g., plasma exchange, cell depletion also remove healthy blood components during the procedure, which must subsequently be replaced. Prior to TA in every case, the patient must be informed about its action, side reactions and possible therapeutic options.

Key words

Therapeutic apheresis - erythrocyte exchange - plasma exchange - therapeutic cell depletion - lipoprotein apheresis

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