Dear Editor,

Therapeutic apheresis is performed for numerous indications in various medicine fields [1-5]. The primary reference on the use of therapeutic apheresis are the evidence-based guidelines issued by the Writing Committee of the American Society for Apheresis (ASFA) [6]. These guidelines provide structured evidence for therapeutic apheresis and are offered for medical consideration worldwide. Recently, new guidelines were issued by the Japanese Society for Apheresis (JSFA) [7]. The main difference between the two guidelines lies in the primary modality used in each country and clinical indications for therapeutic apheresis. The primary apheresis modality used in Japan is the membrane separation method, whereas in the USA, the centrifugal separation method is mainly used. As the target diseases and their backgrounds differ between these countries, there was a need to develop new guidelines in Japan.

The most noticeable difference between the ASFA and JSFA guidelines is that various new techniques are suggested in the latter. New technologies and tools have been developed and applied in clinical apheresis in Japan, including hollow-fiber devices such as double filtration plasmapheresis (DFPP), adsorption devices such as polymyxin B-immobilized endotoxin adsorption columns, and selective plasma exchange devices. In the JSFA guidelines, out of four categories, plasma filtration with dialysis (PDF) for liver failure is classified as category II, implying that therapeutic apheresis can be applied as a second-line therapy, independent of plasma exchange and continuous hemodiafiltration (CHDF) for acute liver failure (category I). In the ASFA guidelines, plasma exchange is the only option suggested for acute liver failure. As for the diseases included in the two guidelines, 39 diseases are included only in the ASFA guidelines and 32 diseases only in the JSFA guidelines (Table 1). This likely reflects the variability in the prevalence of certain diseases according to country and ethnicity. Specifically, babesiosis, malaria, and sickle cell disease are included only in the ASFA guidelines as their prevalence in Asia is extremely low. Extracorporeal photopheresis (ECP) for graft-versus-host disease (GVHD) is classified into category II in the ASFA guidelines, whereas there is no mention of ECP for GVHD in the JSFA guidelines.

Guidelines for therapeutic apheresis have yet to be developed in Korea. At present, medical decisions and national health insurance reimbursements for apheresis are based on the ASFA guidelines. Like in the USA, the main modality used for clinical apheresis in Korea is centrifugal separation. However, the target diseases are closer to those in Japan because of shared ethnic and geographical backgrounds. Due to the language barrier, literature published in Korean was not included in either of the guidelines. There is a need to develop Korean guidelines on therapeutic apheresis using both guidelines as a reference, while considering Korea’s unique demands. For example, severe fever with thrombocytopenia syndrome (SFTS) is uncommon in the USA and is therefore not included in the ASFA guidelines. Despite there being a few cases of SFTS in Japan, it is not included in the JSFA guidelines either. However, in Korea, the incidence of SFTS is relatively high, at 200–250 cases annually, and the clinical utility of therapeutic plasma exchange (TPE) for the treatment of SFTS has been suggested in case reports [8, 9]. In the guidelines published by the Korea Disease Control and Prevention Agency, TPE has been suggested as a treatment option for removing cytokines in SFTS [10]. New Korean guidelines should be introduced that enable the clinical application of therapeutic apheresis for diseases unique to the Korean population as well as the reimbursement from insurance for apheresis in such cases.

The frequency and modalities used for apheresis in different diseases vary among countries, as does the reimbursement from insurance [5]. Optimal guidelines for clinical apheresis should be established for each country’s unique population and could guide physicians in deciding whether to perform apheresis. There should be continuous academic and political efforts to establish clinical apheresis guidelines in Korea.