Still a role for plasma exchange in rapidly progressive glomerulonephritis?

Plasmapheresis combined with immunosuppression dramatically improved the survival of patients with Goodpasture's disease in the late 1970's. The presence of circulating pathogenic autoantibodies in this disease provided a logical rationale for the use of plasma exchange therapy. Careful analysis of the response to treatment has suggested that patients presenting with a serum creatinine < 600 mumol/I have the most benefit from plasma exchange. Subsequently plasmapheresis has been tried in a variety of other nephritides, predominantly those causing rapidly progressive glomerulonephritis, with variable success. Initial studies failed adequately to distinguish patients with a number of quite distinct causes of crescentic nephritis. However it has become clear that plasma exchange significantly improves the outcome of patients with pauci-immune crescentic glomerulonephritis who present with severe renal failure requiring dialysis, but not those with less severe renal disease.