Indications for Immunoglobulin Apheresis

Main Indications

The American Society of Hematology recommends plasmapheresis/apheresis as first-line therapy for symptomatic hyperviscosity due to paraproteinemia 2
The European Society for Immunodeficiencies suggests that severe cryoglobulinemia with acute kidney involvement, neurological complications, or hyperviscosity syndrome may benefit from apheresis 1
Preventive plasmapheresis before rituximab therapy may be considered in patients with IgM ≥ 4 g/dL to avoid symptomatic IgM flares, according to the American Society of Clinical Oncology 2

The American Academy of Neurology recommends IVIG or plasmapheresis as first-line therapies for severe Guillain-Barré syndrome (grade 3-4) 3, 4
The European Federation of Neurological Societies suggests that plasmapheresis is a first-line therapy for myasthenia gravis 5
IgM-associated neuropathy with an aggressive course may benefit from apheresis, according to the American Society of Hematology 2
Severe immune-mediated neuropathies, especially with rapid progression, may require apheresis, as recommended by the American Academy of Neurology 3

Severe myositis (grade 3-4) that does not respond to corticosteroids may benefit from apheresis, according to the European Society of Medical Oncology 4
Immune-mediated adverse events due to checkpoint inhibitors, especially neurological toxicities, may require apheresis, as suggested by the European Society for Medical Oncology 5

Plasma exchange and double filtration are considered the best apheretic approaches, according to the American Society for Apheresis 1
In life-threatening complications, plasma exchange is often preferred, as recommended by the American Society for Apheresis 1

Caution should be exercised when using apheresis in patients with severe HCV liver disease, according to the American Association for the Study of Liver Diseases 1
Close monitoring of HCV or HBV infection after apheresis is necessary, especially when combined with immunosuppressants, as recommended by the American Association for the Study of Liver Diseases 1
Combination with cyclophosphamide or other immunosuppressants requires special caution, according to the American Society of Clinical Oncology 1, 6
After Ig apheresis, monitoring of IgG trough levels, blood counts, and serum chemistry is necessary, as suggested by the American Academy of Allergy, Asthma, and Immunology 7