Rheopheresis in hemodialysis patients with limb ulcers or amputation: safety and outcomes from a multicenter cohort

Limb ulcers are common in hemodialysis (HD) and often have a poor prognosis despite standard care. Rheopheresis is a plasmapheresis technique that reduces blood viscosity and erythrocyte aggregation and has been proposed as an adjunctive therapy, but no study has yet compared it to standard care alone. We conducted a retrospective multicenter study comparing 61 hemodialysis (HD) patients treated with rheopheresis for limb ulcer or amputation in five French dialysis centers with 119 HD patients receiving standard care matched on age, lesion type, and lesion site. Outcomes were analyzed using propensity score–matched cohorts. The primary outcome was 1-year amputation-free survival (AFS). One-year AFS reached 58.9% (95% CI: 45.1; 70.4) in the rheopheresis cohort and 28.8% (95% CI: 20.9; 37.2) in the standard care cohort. This difference did not reach statistical significance after adjustment for immortal-time bias (HR: 1.28, 95% CI: 0.72–2.25). Secondary outcomes followed similar trends, slightly in favor of rheopheresis without reaching significance. Major adverse events occurred in only 2.4% of rheopheresis sessions, and no treatment-related deaths were reported. Rheopheresis was well tolerated and demonstrated a favorable safety profile. Clinical outcomes were numerically better with rheopheresis compared to standard care, although differences did not reach statistical significance. These findings suggest a potential benefit, warranting larger prospective studies.