A Case Report

A case of myoclonic status treated with plasmapheresis in a patient of 63 years of age who was admitted to a Spanish intensive care unit is reported. The patient showed clinical and radiological evidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection; molecular tests did not verify this.

Bleeding outcomes of inpatients receiving therapeutic plasma exchange: A propensity-matched analysis of the National Inpatient Sample

BACKGROUND

Although therapeutic plasma exchange (TPE) is associated with hemostatic abnormalities, its impact on bleeding outcomes is unknown. Therefore, the main study objective was to determine bleeding outcomes of inpatients treated with TPE.

STUDY DESIGN AND METHODS

In a cross-sectional analysis of the National Inpatient Sample (NIS), discharges were identified with 10 common TPE-treated conditions. A 1:3 propensity-matched analysis of TPE- to non-TPE-treated discharges was performed. The primary outcome was major bleeding and secondary outcomes were packed red blood cell (PRBC) transfusion, mortality, disposition, hospital length of stay (LOS), and charges. Multivariable regression analyses were used to examine the association between TPE and study outcomes.

RESULTS

The study population was 15,964 discharges, of which 3991 were TPE- treated. The prevalence of major bleeding was low (5.4%). When compared to non-TPE discharges, TPE had a significant and positive association with major bleeding (OR = 1.37, 95% CI: 1.16-1.63, p = .0003). TPE was also associated with PRBC transfusion (OR = 1.66, 95% CI: 1.42-1.94, p < .0001), in-hospital mortality (OR = 1.45, 95% CI: 1.10-1.90, p = .0008), hospital length of stay (12.45 [95% CI: 11.95-12.97] vs. 7.38 [95% CI: 7.12-7.65] days, p < .0001) and total charges, ($125,123 [95% CI: $119,220-$131,317] vs. $61,953 [95% CI: $59,391-$64,625], p < .0001), and disposition to non-self-care (OR = 1.29, 95% CI: 1.19-1.39, p < .0001).

DISCUSSION

The use of TPE in the inpatient setting is positively associated with bleeding; however, with low prevalence. Future studies should address risk factors that predispose patients to TPE-associated bleeding.

Acute Pancreatitis as a Trigger for Thrombotic Microangiopathy: A Case Report

Thrombotic microangiopathies (TMA) are a group of disorders characterized by generalized microvascular occlusion, thrombocytopenia, and microangiopathic hemolytic anemia, which may present with organ dysfunction. These include hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP) among others. The triad of anemia, thrombocytopenia, and acute kidney injury is the hallmark of HUS. It can be associated with Shiga toxin-producing Escherichia coli infection, complement-mediated (atypical HUS), coagulation or metabolism-mediated (predominantly in children of less than one year of age), or secondary HUS with the coexisting disease. HUS is a potentially fatal condition irrespective of its cause, and hence the diagnosis and management approach must be swift. The treatment is support-based; however, in severe cases, the use of plasmapheresis has shown favorable outcomes. In this report, we discuss a case of a 30-year-old male who presented with acalculous acute pancreatitis with HUS, a rare case of secondary HUS previously reported in a few case reports.

Therapeutic Use of Convalescent Plasma in COVID-19 Infected Patients with Concomitant Hematological Disorders

The use of convalescent plasma (CP) from individuals recovered from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a promising therapeutic modality for the coronavirus disease 2019 (COVID-19). CP has been in use for at least a century to provide passive immunity against a number of diseases, and was recently proposed by the World Health Organization for human Ebola virus infection. Only a few small studies have so far been published on patients with COVID-19 and concomitant hematological malignancies (HM). The Italian Hematology Alliance on HM and COVID-19 has found that HM patients with COVID-19 clinically perform more poorly than those with either HM or COVID-19 alone. A COVID-19 infection in patients with B-cell lymphoma is associated with impaired generation of neutralizing antibody titers and lowered clearance of SARS-CoV-2. Treatment with CP was seen to increase antibody titers in all patients and to improve clinical response in 80% of patients examined. However, a recent study has reported impaired production of SARS-CoV-2-neutralizing antibodies in an immunosuppressed individual treated with CP, possibly supporting the notion of virus escape, particularly in immunocompromised individuals where prolonged viral replication occurs. This may limit the efficacy of CP treatment in at least some HM patients. More recently, it has been shown that CP may provide a neutralising effect against B.1.1.7 and other SARS-CoV-2 variants, thus expanding its application in clinical practice. More extensive studies are needed to further assess the use of CP in COVID-19-infected HM patients.

Comparison of plasmapheresis with medical apheresis in terms of efficacy and cost in the acute treatment of hypertriglyceridemia in children with lipoprotein lipase deficiency

OBJECTIVES

We aimed to compare plasmapheresis and medical apheresis as lipid-lowering therapies in children with familial lipoprotein lipase (LPL) deficiency.

METHODS

The data of 13 patients who were followed up after a diagnosis of LPL deficiency were retrospectively analyzed. Plasma triglyceride, cholesterol, amylase, and lipase values and complications were recorded before and after each patient underwent plasmapheresis or medical apheresis.

RESULTS

The mean follow-up period of the patients was 99.64 ± 52.92 months in the medical apheresis group and 118 ± 16.97 months in the plasmapheresis group. While the mean triglyceride level before plasmapheresis was 1,875.38 ± 547.46 mg/dL, it was 617 ± 228.28 mg/dL after plasmapheresis. While the mean triglyceride level before medical apheresis was 1,756.86 ± 749.27 mg/dL, it was found to be 623.03 ± 51.36 mg/dL after medical apheresis. Triglyceride levels were decreased by 59.62% with medical apheresis and 65.57% with plasmapheresis. The cost of treatment for medical apheresis was found to be lower compared to plasmapheresis 296.93 ± 29.94 Turkish lira (USD 43.34 ± 4.01) vs. 3,845.42 ± 156.17 Turkish lira (USD 561.37 ± 20.93; p<0.001).

CONCLUSIONS

Although there is no standardized strategy for the acute treatment of hypertriglyceridemia due to LPL deficiency, medical apheresis is a safe and effective treatment with a low risk of side effects. Unlike plasmapheresis, medical apheresis can be performed in any center, which is another important advantage of the procedure.

Case Report: Therapeutic and immunomodulatory effects of plasmapheresis in long-haul COVID

Many patients with COVID-19 experience a range of debilitating symptoms months after being infected, a syndrome termed long-haul COVID. A 68-year-old male presented with lung opacity, fatigue, physical and cognitive weaknesses, loss of smell and lymphocytopenia. After rounds of therapeutic plasma exchange (TPE), the patient returned to normal activities and work. Mechanistically in the patient's peripheral blood mononuclear cells (PBMCs), markers of inflammatory macrophages diminished and markers of lymphocytes, including natural killer (NK) cells and cytotoxic CD8 T-cells, increased. Circulating inflammatory proteins diminished, while positive regulators of tissue repair increased. This case study suggests that TPE has the capacity to treat long-haul COVID.

Case Report: Therapeutic and immunomodulatory effects of plasmapheresis in long-haul COVID

Many patients with COVID-19 experience a range of debilitating symptoms months after being infected, a syndrome termed long-haul COVID. A 68-year-old male presented with lung opacity, fatigue, physical and cognitive weaknesses, loss of smell and lymphocytopenia. After rounds of therapeutic plasma exchange (TPE), the patient returned to normal activities and work. Mechanistically in the patient's peripheral blood mononuclear cells (PBMCs), markers of inflammatory macrophages diminished and markers of lymphocytes, including natural killer (NK) cells and cytotoxic CD8 T-cells, increased. Circulating inflammatory proteins diminished, while positive regulators of tissue repair increased. This case study suggests that TPE has the capacity to treat long-haul COVID.

Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series

Rationale:

Protocols for regional citrate anticoagulation with the hypertonic 4% trisodium citrate solution have been recently described as an anticoagulation strategy during membrane therapeutic plasma exchange (mTPE). The effect of citrate in the patient’s systemic hemostasis is negligible, thus regional citrate anticoagulation application is advantageous in circumstances in which heparin-based protocols are deemed unsafe for patients with a high risk of bleeding. The downsides of using hypertonic citrate solutions are mainly hypocalcemia and hypernatremia that ultimately can cause adverse clinical events.

Presenting concerns of the patient:

(1) A 57-year-old Caucasian female with a history of active vaginal bleeding secondary to endometrial hyperplasia. She had a history of antiphospholipid syndrome, and systemic lupus erythematosus with marked refractory autoimmune thrombocytopenia. Her platelet count was persistently below 4,000/mm³ even after different immunosuppressive regimens and daily platelet transfusions. (1) A 70-year-old Caucasian female was hospitalized presenting acute kidney injury stage 3 due to rapidly progressive antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, however without the need for renal replacement therapy. At admission, serum creatinine (sCr) was 3.56 mg/dL (normal range: 0.53-1.00 mg/dL). Her baseline sCr was 0.8 mg/dL obtained 6 months earlier. Chest tomography revealed bilateral masses compatible with granulomatous lesions and no signs of alveolar bleeding. Since severe cases of ANCA vasculitis involving the lungs may evolve with alveolar hemorrhage, heparin was avoided.

Diagnoses:

(1) Systemic lupus erythematosus-associated autoimmune thrombocytopenia and (2) ANCA-associated vasculitis with kidney and lung involvement.

Interventions:

Herein, we describe a case series of 12 consecutive mTPE treatments in 2 different patients using regional 4% trisodium citrate anticoagulation.

Outcomes:

All the sessions were uneventful, presented only minor electrolyte imbalances, and were effectively completed without early interruptions due to clotting of the plasmafilter.

Teaching points:

In our 2 cases, extracorporeal regional citrate anticoagulation was successful in optimizing plasmafilter patency without bleeding events in 2 high-risk patients using established protocols for the citrate and calcium infusions.

Temporal Clustering of Antiglomerular Basement Membrane Disease in COVID-19 Pandemic: A Case Series

Anti-glomerular basement membrane disease (anti-GBM) affects mainly kidneys and lungs. It requires aggressive immunosuppressive treatment. Since the emergence of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), there has been an increased number of new cases of anti-GBM disease presenting as rapidly progressive glomerulonephritis (RPGN). The causal relationship is still speculative. We report a case series of four patients affected with COVID-19 infection presenting later with anti-GBM disease.

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Plasma Exchange in ANCA-Associated Vasculitis: A Narrative Review

Therapeutic plasma exchange (TPE) is an adjunctive intervention to immunosuppression for the treatment of severe renal involvement or lung hemorrhage in patients with ANCA-associated vasculitis (AAV). Patients with AAV have an increased risk for progression to end-stage kidney disease (ESKD) or death despite advances in immunosuppressive therapy. The potential pathogenicity of ANCA makes TPE a reasonable treatment approach for the life-threatening complications of AAV. The efficacy of intensive TPE in rapidly progressive glomerulonephritis was originally described in small studies almost four decades ago. Further randomized trials examined the addition of TPE to standard of care, exhibiting mixed results in both patient and renal survival. The largest clinical trial to date, PEXIVAS, failed to demonstrate a clear benefit for TPE in severe AAV. In light of new evidence, the role of TPE remains controversial across the vasculitis medical community. The purpose of this review is to summarize the clinical indications and the current available data for the use of TPE in patients with severe AAV.

Hypertriglyceridemia Induced Pancreatitis: plasmapheresis or conservative management?

INTRODUCTION

Hypertriglyceridemia-induced acute pancreatitis (HIAP) may result in severe morbidity and mortality. The most effective management strategy is unknown. While plasmapheresis is often performed, it is possible that a conservative approach which includes fasting, intravenous fluids and high-dose insulin, may be successful.

OBJECTIVES

To compare the 28 day mortality and morbidity parameters among patients admitted to the intensive care unit (ICU) due to HIAP when treated conservatively, as compared to patients who were treated with plasmapheresis.

MATERIALS AND METHODS

A retrospective study was performed, including all patients at least 18 years of age who were admitted to the ICU between the years 2010 to 2020 with diagnosis of HIAP. Patients underwent plasmapheresis or were managed conservatively. Collected data included patient demographics, chronic illness and medications, hospital and ICU admission times, 28-day mortality, need for ventilation, number of ventilation days, need for inotropic support, daily triglyceride levels, APACHE II score, lactate on admission, need for dialysis, antibiotic treatment, surgical or percutaneous intervention.

RESULTS

The study included 29 patients. Twenty two patients were treated conservatively and 7 patients with plasmapheresis. There were no significant statistical differences between the groups regarding demographic parameters, chronic disease and medications. Furthermore, on ICU admission and during the subsequent 4 days APACHE score, serum lactate and triglyceride levels were similar between the groups. There was no significant difference in mortality. However, plasmapheresis was associated with greater morbidity (longer admission times, need for ventilation and number of ventilation days, need for inotropic support and dialysis, and invasive surgical intervention). Finally, when compared to conservative management, the rate of serum triglyceride decrease was not improved following plasmapheresis.

CONCLUSION

Efficacy of conservative treatment in lowering the serum triglyceride level in HIAP is similar to plasmapheresis. Due to the small patient cohort further prospective studies are needed to confirm these findings.

Re-transplantation in pediatric patients with failure of primary transplant due to recurrent focal segmental glomerulosclerosis: A pediatric nephrology research consortium study

INTRODUCTION

Recurrent focal and segmental glomerulosclerosis (FSGS) in kidney transplant recipients is associated with lower graft survival and increased morbidity. There are limited data to guide the decision to re-transplant patients with transplant failure due to FSGS recurrence. We aimed to evaluate outcomes in patients re-transplanted after having initial graft failure due to recurrent FSGS and to study physician attitudes and practice patterns.

METHODS

Retrospective data from 10 centers were collected on 20 patients transplanted between January 1997 and September 2018. A survey was sent to nephrologist members of the Pediatric Nephrology Research Consortium.

RESULTS

Mean patient age (years) was 9.8 ± 4.8 at first transplant and 15.9 ± 4.9 at re-transplantation. Pre-transplant plasmapheresis was used in 1 (5.3%) primary transplant vs. 7 (38.9%) re-transplants (p = .03). Nephrotic syndrome recurred in 14 patients (70%) after re-transplantation and was severe in 21.1% vs. 64.7% after first transplant (p = .04). Graft survival was significantly higher in the second transplant (p .009) with 70% having functioning grafts at a median of 25.2 months. Thirty-one physicians from 21 centers completed the survey, 94% indicated they would re-transplant such patients, 44.4% preferred a minimum waiting period before re-transplantation, 36.4% preferred living donors, and 22.2% indicated having protocols for re-transplantation at their centers.

CONCLUSIONS

Consideration for re-transplantation is high among pediatric nephrologists. Pre-transplant plasmapheresis was more frequent in re-transplanted patients. Nephrotic syndrome recurrence was less severe, with better graft survival. More data and a larger population are necessary to further evaluate outcome determinants and best practices in this special population.

Rare Case Report of De-novo Pauci-immune Necrotizing Crescentic Glomerulonephritis in 1st-week Post-kidney Transplantation

Early post-transplant de-novo pauci-immune necrotizing crescentic glomerulonephritis occurring within the first week post transplantation has not been reported according to the literature search done by us. Here, we are reporting a 56 years male patient who underwent living spousal donor kidney transplantation for presumed diabetic nephropathy, and developed pauci-immune necrotizing crescentic glomerulonephritis (NCGN) on sixth day post-transplant. Post-renal transplant recurrence of disease in ANCA-associated vasculitis patients occurs within days to months. However, development of de-novo pauci-immune crescentic glomerulonephritis is a rare occurrence. We report this patient who developed probable pauci-immune de-novo NCGN which responded to treatment with plasmapheresis, steroids and cyclophosphamide.

Investigation of plasma exchange and hemoperfusion effects and complications for the treatment of patients with severe COVID-19 (SARS-CoV-2) disease: A systematic scoping review

Some previous studies suggested that the plasma exchange (PE) and hemoperfusion (HP) played a cardinal role in the treatment of severe coronavirus disease 2019 (COVID-19) cases by diminishing the cytokine storm. This study aimed to assess the effects of PE and HP on cytokine storms in patients with severe COVID-19 through a systematic scoping review. Four Electronic databases (Medline [accessed from PubMed], Scopus, Science Direct, and Cochrane library) were searched systematically on February 2, 2021, using MESH terms and related keywords in the English language. Considering the titles and abstracts, unrelated studies were excluded. The full texts of the remained studies were evaluated by authors, independently. Then, their findings were assessed and reported. A total of 755 articles were obtained within the first step of searching, and 518 remained after removing the duplications. Through the title and abstract screening, 438 were removed. Of the rest, 59 papers were excluded. Finally, after reading the full text of the remained articles, 21 were included in data extraction. Most of the previously reported evidence were case reports and case series. Findings were summarized in two categories. The first category encompassed nine studies regarding HP and continuous renal replacement therapy, and the second category included twelve studies about PE. The results revealed that HP and PE within the cytokine storm phase would be beneficial with a high probability in the treatment of severely ill COVID-19 patients. Highlights Some studies showed that plasma exchange (PE) and hemoperfusion (HP) played an important role in the treatment of patients with severe COVID-19 disease. The results of this systematic scoping review revealed that HP and PE within the cytokine storm phase would be beneficial with a high probability in the treatment of severely ill COVID-19 patients.

Combination treatment with rituximab, low-dose cyclophosphamide and plasma exchange for severe antineutrophil cytoplasmic antibody-associated vasculitis

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis can present with life-threatening lung-kidney syndromes. However, many controlled treatment trials excluded patients with diffuse alveolar hemorrhage or severely impaired glomerular filtration rates, and so the optimum treatment in these cases is unclear. In this retrospective cohort study, we report the outcomes of 64 patients with life-threatening disease treated with a combination regimen of rituximab, low-dose intravenous cyclophosphamide, oral glucocorticoids, and plasma exchange. At entry, the median estimated glomerular filtration rate was 9 mL/min, 47% of patients required dialysis, and 52% had diffuse alveolar hemorrhage. All patients received a minimum of seven plasma exchanges, and the median cumulative doses of rituximab, cyclophosphamide, and glucocorticoid were 2, 3, and 2.6 g, respectively, at six months. A total of 94% of patients had achieved disease remission (version 3 Birmingham Vasculitis Activity Score of 0) at this time point, and 67% of patients who required dialysis recovered independent kidney function. During long-term follow-up (median duration 46 months), overall patient survival was 85%, and 69% of patients remained free from end-stage kidney disease, which compares favorably to a historic cohort with severe disease treated with a conventional induction regimen. Combination treatment was associated with prolonged B cell depletion and low rates of relapse; 87% of patients were in continuous remission at month 36. The serious infection rate during total follow-up was 0.28 infections/patient/year, suggesting that combination treatment is not associated with an enduring risk of infection. Thus, we suggest that combination immunosuppressive therapy may permit glucocorticoid avoidance and provide rapid and prolonged disease control in patients with severe ANCA-associated vasculitis.

Plasmapheresis as an Early Treatment for Severe Hypertriglyceridemia, Acute Pancreatitis, and Diabetic Ketoacidosis

Objective

Severe hypertriglyceridemia (SHTG; plasma triglycerides >1000 mg/dL) is a rare but serious complication in children who develop diabetic ketoacidosis (DKA) from uncontrolled or new-onset type 1 diabetes.

Methods

We present the case of a severely malnourished 16-year-old with a 10-month history of presumed type 2 diabetes managed with lifestyle modifications and metformin, who presented with SHTG, acute pancreatitis, and DKA. On examination, there was no evidence of lipemia retinalis, cutaneous xanthomas, or xanthelasma. He was initially treated with an insulin infusion and intravenous fluids. Despite this treatment, his pancreatitis symptoms worseneed and lipase level increased, necessitating 2 courses of plasmapheresis that immediately resolved his symptoms and dramatically improved his clinical status. He was discharged on hospital day 5. During his hospital admission, islet cell antigen 512, insulin, glutamic acid decarboxylase 65, and zinc transporter 8 autoantibodies were positive in the presence of insulinopenia, consistent with type 1 diabetes.

Results

Hypertriglyceridemia and hypercholesterolemia did not recur during follow-up, suggesting that the underlying mechanism for SHTG was insulin deficiency.

Conclusion

This report of SHTG, DKA, and pancreatitis in an adolescent highlights the safe, early initiation of plasmapheresis as an effective treatment. To our knowledge, plasmapheresis has rarely been used so early in the course of treatment for an adolescent with SHTG, DKA, and acute pancreatitis.

Mycophenolate Mofetil and Plasmapheresis: A Treatment Option for Severe Insulin Resistance caused by Insulin Antibodies

Objective

Insulin antibody (IA)-mediated insulin resistance (IR) is a rare condition for which immunosuppressive regimens have been described. However, these raise the risk of infection, and the drugs may not be effectively metabolized in patients with liver disease. A 61-year old male with type 2 diabetes mellitus and antibody-mediated IR who required >800 units of daily insulin presented with acute decompensation of his preexisting cirrhosis from recurrent diabetic ketoacidosis. Laboratory tests confirmed an IA level of >625 μU/mL (reference: <5.0 μU/mL).

Methods

Centrifugal plasmapheresis and mycophenolate mofetil (MMF) were used to treat the patient to achieve glycemic control. Continuous glucose monitoring was implemented to monitor glycemic control pre- and posttherapy. Laboratory evaluation included levels of IA, C-peptide, insulin-like growth factor-1, growth hormone, salivary cortisol, zinc transporter 8, glutamic acid decarboxylase 65-kilodalton isoform antibody, and islet-cell antibodies.

Results

We initiated MMF followed by 5 sessions of plasmapheresis, leading to an overall 77.3% reduction from pretherapy insulin requirements after 6 months without further episodes of diabetic ketoacidosis or infection. The cirrhosis stabilized, and there was an improvement in HbA1C from 8.7% (72 mmol/mol) to 6.6% (49 mmol/mol) and time in euglycemic range from 30% to 61%.

Conclusion

This is the first report of MMF and centrifugal plasmapheresis use to mitigate the effects of IA-mediated IR in a patient with cirrhosis. We recommend further studies to determine the utility of this treatment to improve care for patients at high risk for IA-mediated IR.

Acute liver failure due to herpes simplex virus: diagnostic clues and potential role of plasmapheresis: A case report

INTRODUCTION

Acute liver failure (ALF) is a life-threatening condition that remains challenging for physicians despite several advances in supportive care. Etiologies vary worldwide, with herpes simplex virus (HSV) hepatitis representing less than 1% of cases. Despite its low incidence, ALF is a lethal cause of acute necrotizing hepatitis and has a high mortality. Early antiviral treatment is beneficial for survival and decreased liver transplantation necessity. However, plasmapheresis, despite its theoretical potential benefit, is scarcely reported.

PATIENT CONCERNS

A 25-year-old woman with no known disease presented with painful pharynx ulcers, increased transaminases and impaired liver function.

DIAGNOSIS

ALF due to a disseminated HSV-2 primary infection was diagnosed with a positive polymerase chain reaction for HSV-2 in the biopsied liver tissue and blood.

INTERVENTIONS

Empiric antiviral treatment was initiated. After clinical deterioration, plasmapheresis was also initiated.

OUTCOMES

After 6 cycles of plasmapheresis and supportive care, the patient's condition improved without undergoing liver transplantation.

CONCLUSIONS

ALF is a life-threatening condition, and HSV as an etiology must be suspected based on background, clinical manifestation, and laboratory information. The potential role of plasmapheresis in HSV hepatitis should be considered.

Therapeutic Plasma Exchange in Myasthenia Gravis: A Systematic Literature Review and Meta-Analysis of Comparative Evidence

Background: Patients with Myasthenia Gravis (MG) can be treated acutely with therapeutic plasma exchange (TPE) or intravenous immune globulin (IVIG). To date, there is no definitive understanding of which of the two treatments is more effective and safer. The purpose of this study was to systematically review the literature on the comparative efficacy and safety of TPE to other available treatments for MG. Methods: A systematic literature search for studies published between 1997 and 2017 was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using two database sources, MEDLINE (through the PubMed database) and Cochrane Library. Results: The search strategy resulted in 535 articles whose abstracts were reviewed. Among these, 165 full texts articles were reviewed for eligibility and 101 articles were excluded. Of the 165 articles, 64 articles were included for a systematic literature and 11 articles for a meta-analysis. Conclusions: This systematic literature review and meta-analysis of treatment options showed that there was a higher response rate with TPE than IVIG in acute MG patients and patients undergoing thymectomy. There was no difference in mortality between the two treatment options. Our findings highlight the need for additional randomized clinical trials in these patients with MG.

Thrombotic Thrombocytopenic Purpura Presentation in an Elderly Gentleman Following COVID Vaccine Circumstances

Thrombotic thrombocytopenic purpura (TTP) is a rare blood disorder that results in the formation of thrombi in the small blood vessels throughout the body. The two primary forms of TTP are acquired and familial forms. The acquired form usually presents in late childhood or adulthood. Almost 95% of the cases are due to an autoantibody directed against ADAMTS13, and the remaining 5% are due to drugs like ticlopidine, quinine, cyclosporine, gemcitabine, bevacizumab, and certain recreational drugs like ecstasy and cocaine. The familial forms present in infancy or early childhood, but sometimes they can present later in life. Management for acquired forms includes therapeutic plasma exchange and immunosuppressive agents. While for the hereditary forms, the mainstay of treatment is plasma infusion.

We present a case of an 80-year-old male with a known medical history of hypertension, type II diabetes mellitus, hyperlipidemia, gout, iron deficiency anemia, and Pfizer-BioNTech COVID-19 (coronavirus disease-19) vaccine administered two weeks before presentation to the ER for evaluation of generalized weakness and malaise. Laboratory findings showed severe anemia with hemoglobin of 4.8 g/dl, platelet count of 48 x 10^3/mcL, elevated lactate dehydrogenase (LDH), decreased haptoglobin, and peripheral smear showing schistocytes. The serum creatinine, total bilirubin, and troponin were elevated. All these findings were raising concern for presumptive diagnosis of TTP, which was confirmed with ADAMTS13 levels less than 10%. TTP was temporarily resolved in 10 days with plasma exchange therapy and high-dose corticosteroids.

It is difficult at this time to differentiate vaccine‐induced TTP from coincidental TTP presenting soon after vaccination. Further studies would be needed to understand better if this relationship between vaccination and TTP was coincidental or causal.

First report of a de novo iTTP episode associated with an mRNA-based anti-COVID-19 vaccination

Thrombotic thrombocytopenic purpura (TTP) is a rare but potentially life-threatening thrombotic microangiopathy, characterized by disseminated thrombus formation in the microvasculature, causing severe organ failure. Immune-mediated TTP (iTTP) is occasionally described after vaccination, especially against viral agents. We report a case of a 38-year-old woman with a de novo iTTP after exposure to the mRNA-based anti-coronavirus disease 2019 (COVID-19) vaccine produced by Pfizer-BioNTech. She presented with increased bruising and petechiae starting 2 weeks after receiving the first dose of the anti-COVID-19 vaccine. Laboratory data revealed a severe ADAMTS13-deficiency in combination with a very high autoantibody titer against ADAMTS13. She was successfully treated with plasma exchange, corticosteroids, rituximab, and caplacizumab. To our knowledge, this is the first case report of iTTP after mRNA-based COVID-19 vaccination in a previously TTP-naïve patient.

Therapeutic plasmapheresis for the treatment of thyrotoxicosis: A retrospective multi-center study

BACKGROUND AND AIMS

Thyroid storm and severe thyrotoxicosis remain among the most frequent endocrine emergencies, and first-line hyperthyroidism treatment is not always an option. Since the first report in 1970, plasmapheresis is a second-line treatment for severe or otherwise untreatable thyrotoxicosis when rapid euthyroidism is desired.

METHODS

We present a retrospective study of the experience in treating thyrotoxicosis with plasmapheresis between 2012 and 2020 in two specialized centers in Colombia. We register the demographic and clinical characteristic and compare the thyroid hormones and other biochemical measurements before and after treatment.

RESULTS

Data from 19 patients was obtained, 58% female with a median age of 35 years (IQR 23.5), and most of them with Graves' disease. The most frequent indication for plasmapheresis was thyroid storm. A median of 4 (IQR 2) sessions lead to a significant reduction in FT4 (P .0001) and TT3 (P < .0003) with a nonsignificant decrease in beta-blocker (P .7353) dose, no change in hepatic enzymes, and no adverse events. After plasmapheresis, thyroidectomy was performed in 10 patients.

CONCLUSIONS

Plasmapheresis is an effective and safe treatment option for reducing circulating thyroid hormones in severe thyrotoxicosis when other forms of treatment are contraindicated or in case of urgent thyroid and non-thyroid surgery. It is limited by its cost and the need for highly specialized resources.

The impact of the COVID-19 pandemic on hospitalizations and plasmapheresis therapy in multiple sclerosis and neuromyelitis optica spectrum disorder: a nationwide analysis from Germany

Background:

Many countries worldwide reported side effects of the coronavirus disease 2019 (COVID-19) pandemic that have influenced the care of patients with other diseases in both acute and elective settings. Patients with multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) represent the major patient population suffering from an autoimmune inflammatory demyelinating disease of the central nervous system. We aimed to analyze MS and NMOSD hospitalizations, the application of plasmapheresis therapy, and the dynamic during different periods of the COVID-19 pandemic in Germany.

Methods:

We conducted a nationwide retrospective cross-sectional study using the administrative database of all hospitalized patients with the main diagnosis of MS and NMOSD, including the information on the application of plasmapheresis therapy. We included full-year data from 1463 hospitals of all MS and NMOSD patients hospitalized in 2019 and 2020 in Germany (n = 87,453). We compared case numbers and plasmapheresis therapy rates of the different pandemic periods in 2020 with the corresponding periods in 2019.

Results:

We observed a substantial decline of MS and NMOSD patients’ hospitalizations during the different pandemic periods, with the most remarkable decline during the first wave of the pandemic (First diagnosis of MS: −16.8%; relapsing-remitting MS: −34.0%; secondary progressive MS: −48.9%; primary progressive MS: −43.8%; NMOSD: −19.2%). Treatment rates with plasmapheresis increased for MS and NMOSD patients in 2020 compared to 2019 (1.8% versus 1.6%, p = 0.003; 14.0% versus 9.3%, p < 0.001), with a substantial increase during the first wave of the pandemic, especially in NMOSD patients (19.7% versus 8.4%, p < 0.001).

Conclusion:

There was a marked decline of MS and NMOSD patients’ hospitalizations during the different pandemic periods in 2020, with the most substantial reduction during the pandemic’s first wave and in progressive MS patients. MS and NMOSD patients who needed rescue relapse treatment continued to receive plasmapheresis therapy in Germany.

Successful High-Volume Plasmapheresis in Acute Liver Failure

Acute liver failure carries a high mortality. At present, liver transplant is the definitive treatment along with standard medical support. In the absence of or as a bridge to liver transplant, several liver assist therapies have been derived. Some of the therapies have shown short-term mortality benefits and transplant-free survival over standard medical treatment alone. High volume plasmapheresis (HVP) is one of such therapies and is readily available in hospitals. We discuss the case of a 28-year-old female who presented with acute liver failure, did not qualify for the liver transplant and successfully underwent HVP. Various regimens of plasmapheresis have been described in the literature of which we used the HVP for pre-determined three days. Our case emphasizes the importance of early initiation of HVP in an acute liver failure patient who did not qualify for liver transplant, and adds to the existing evidence of the utility of this particular type of plasmapheresis over other regimens.

Extracorporeal Therapy in Dermatology

Extracorporeal therapy is a treatment modality where human blood undergoes favorable technical modifications and is reintroduced into the same patient. Since the last four decades this technique has been deployed in the management of difficult and refractory disorders in dermatology. Over a period of time newer techniques like immunoadsorption has emerged and opened new vistas in management of morbid dermatoses. In extracorporeal photopheresis a patient's leukocytes are separated and treated outside with Ultra Violet A in presence of 8-methoxypsoralen. Double filtration plasmapheresis and Immunoadsorption are techniques to remove offending immune complexes. They are safe and reduce the need of toxic medications that are conventionally used in recalcitrant skin diseases. In recent years immunoadsorption is emerging as first-line therapy in condition like immunobullous diseases. High cost is one of the important factors limiting their wider use in developing countries like India. Our review discusses different extracorporeal therapies, their applications, recommendations and guidelines based on various clinical trials.

Benchmarking the centralized urgent plasma exchange service for patients admitted with a diagnosis of suspected acquired thrombotic thrombocytopenic purpura at a large healthcare system

BACKGROUND

Consensus guidelines recommend that therapeutic plasma exchange (TPE) should be started within 4 to 8 hours after the diagnosis of suspected acquired thrombotic thrombocytopenic purpura (aTTP). This study aimed to audit the steps from diagnosis to initiation of plasma exchange at a centralized apheresis service.

METHODS

A retrospective review of the electronic medical record and laboratory information systems from January 1, 2014 to August 31, 2017 was conducted to identify all patients with suspected aTTP undergoing TPE. Demographics, comorbidities, pertinent laboratory tests, and temporal TPE procedural data were collected.

RESULTS

The median (5th-95th percentile) time from request to initiation of TPE was 5.4 (3.2-10.6) hours. TPE was initiated within 8 hours in 94 of the 108 patients (87.0%). The median (5th-95th percentile) time from request to central venous access was 2.5 (0.5-6.9) hours and from request to plasma product issuance from the blood bank was 3.4 (1.6-8.1) hours. aTTP patients in whom TPE was initiated greater than 6 hours from request did not have worse outcomes compared to those with TPE initiation within 6 hours: in-hospital mortality (2/14 [14.3%] vs 2/21 [9.5%], P = 0.66), median length of stay (9.0 [4.7-44.1] vs 8.3 [3.9-27.0] days, P = 0.76), and median number of days to durable platelet count recovery (4.5 [2.0-9.0] vs 4.0 [2.0-18.0] days, P = 0.66).

CONCLUSIONS

The 4 to 8-hour target window from TPE request to initiation appears feasible for a centralized apheresis program servicing a large healthcare system.

How we secured a COVID-19 convalescent plasma procurement scheme in Japan

Background

In order to tackle the COVID‐19 pandemic, a COVID‐19 convalescent plasma (CCP) procurement program was initiated in Japan in April 2020. The program was a collaboration between a government‐managed national hospital, an infectious disease research institute, and a blood banking organization. Each party assumed different responsibilities: recruitment, SARS‐CoV‐2 antibody profiling, and plasmapheresis; conduction of screening tests; and SARS‐CoV‐2 blood testing, respectively.

Methods

We adopted a two‐point screening approach before the collected CCP was labeled as a CCP product for investigational use, for which we mainly tested anti‐SARS‐CoV‐2 antibody eligibility and blood product eligibility. Anti‐SARS‐CoV‐2 spike protein titer was measured using enzyme‐linked immunosorbent assay, and the IC₅₀ value was denoted as the neutralizing activity. Blood donor eligibility was extended beyond the normal blood donation guidelines to include a broader range of participants. After both eligibility criteria were confirmed, participants were asked to revisit the hospital for blood donation, which is a unique aspect of the Japanese CCP program, as most donations are taking place in normal blood donation venues in other countries. Some donors were re‐scheduled for repeat plasma donations. As public interest in anti‐SARS‐CoV‐2 antibodies increased, test results were given to the participants.

Results

As of September 17, 2020, our collection of CCP products was sufficient to treat more than 100 patients. As a result, projects for administration and distribution are also being conducted.

Conclusions

We successfully implemented a CCP procurement scheme with the goal to expand to other parts of the country to improve treatment options for COVID‐19.

A rare case of diabetic ketoacidosis presenting with severe hypertriglyceridemia requiring plasmapheresis in an adult with type-2 diabetes mellitus: Case report

INTRODUCTION

Severe hypertriglyceridemia (HTG) is a rare complication of insulin resistance. Its presentation with diabetic ketoacidosis (DKA) has been reported in a few cases, where most patients have type-1 diabetes mellitus (DM). Our case represents a unique presentation of DKA associated with severe HTG above 10,000 mg/dL in an adult with type-2 DM.

PATIENT CONCERNS AND DIAGNOSIS

Case Report: A 51-year-old man with no prior illnesses presented to the emergency department with abdominal pain and nausea. He was found to have DKA with a blood glucose level of 337 mg/dL, pH of 7.17, beta-hydroxybutyrate of 7.93 mmol/L, and anion gap of 20 mmol/L. His triglyceride levels were >10,000 mg/dL. His serum was found to be lipemic. Computerized tomography scan of the abdomen demonstrated mild acute pancreatitis. Negative GAD65 antibodies supported the diagnosis of type-2 DM.

INTERVENTIONS AND OUTCOMES

Endocrinology was consulted and one cycle of albumin-bound plasmapheresis was administered. This therapy significantly improved his HTG. DKA gradually resolved with insulin therapy as well. He was discharged home with endocrinology follow-up.

CONCLUSION

This unique case highlights an uncommon but critical consequence of uncontrolled DM. It brings forth the possibility of severe HTG presenting as a complication of uncontrolled type-2 DM. Severe HTG commonly presents with acute pancreatitis, which can be debilitating if not managed promptly. Most patients with this presentation are managed with insulin infusion. The use of plasmapheresis for management of severe HTG has not been well studied. Our case supports the use of plasmapheresis as an effective and rapid treatment for severe HTG.

Streptococcus Pneumoniae-Associated Hemolytic Uremic Syndrome in the Era of Pneumococcal Vaccine

Streptococcus pneumoniae-associated hemolytic uremic syndrome (Sp-HUS) is a serious complication of invasive pneumococcal disease that is associated with increased mortality in the acute phase and morbidity in the long term. Recently, Sp-HUS definition has undergone revision and cases are categorized as definite, probable, and possible, based on less invasive serological investigations that evaluate Thomsen-Friedenreich crypt antigen (T-antigen) activation. In comparison to the pre-vaccine era, Sp-HUS incidence seems to be decreasing after the introduction of 7-serotype valence and 13-serotype valence pneumococcal vaccines in 2000 and 2010, respectively. However, Sp-HUS cases continue to occur secondary to vaccine failure and emergence of non-vaccine/replacement serotypes. No single hypothesis elucidates the molecular basis for Sp-HUS occurrence, although pneumococcal neuraminidase production and formation of T-antigen antibody complexes on susceptible endothelial and red blood cells continues to remain the most acceptable explanation. Management of Sp-HUS patients remains supportive in nature and better outcomes are being reported secondary to earlier recognition, better diagnostic tools and improved medical care. Recently, the addition of eculizumab therapy in the management of Sp-HUS for control of dysregulated complement activity has demonstrated good outcomes, although randomized clinical trials are awaited. A sustained pneumococcal vaccination program and vigilance for replacement serotypes will be the key for persistent reduction in Sp-HUS cases worldwide.

Myasthenia gravis exacerbation in association with antibody overshoot following plasmapheresis

INTRODUCTION/AIM

Antibody overshoot following therapeutic plasmapheresis (PLEX) is defined by subsequent increase in antibody to levels exceeding those prior to removal. It has been infrequently described in the past, and its influence on the clinical course of myasthenia gravis (MG) remains unclear.

METHODS

This was a retrospective analysis of five patients with generalized MG treated with PLEX.

RESULTS

All five patients possessed antibodies against acetylcholine receptor (AChR-Ab). After undergoing 3 to 12 PLEX treatment sessions, AChR-Ab titer increased to a median of 1292% of the baseline level. The median interval from the last PLEX session to peak AChR-Ab detection was 6 wk. In four patients, AChR-Ab overshoot was associated with a clinical deterioration.

DISCUSSION

The AChR-Ab overshoot may occur following PLEX. In patients who deteriorate following PLEX treatment, the presence of antibody overshoot may serve as additional guidance for treatment adjustment.

A prospective study on COVID-19 convalescent plasma donor (CCP) recruitment strategies in a resource constrained blood centre

Background and Objectives

The COVID-19 pandemic has spread across 87 million people with more than 1·8 million deaths in the world. As there is no definite treatment modality, the use of convalescent plasma has become increasingly popular worldwide. This study aimed to identify an appropriate strategy of donor recruitment and to evaluate the appropriateness of pre-set plasma donation guidelines.

Material and Methods

In this prospective study conducted from May to September 2020, the donors were recruited under the following two circumstances: Group I, patients in the post-COVID-19 follow-up in the clinic, and Group II, patients recovered from COVID-19 recruited through mass and electronic media. A pre-set donor selection criteria and laboratory investigation was designed according to national and international guidelines. Approximately 500 ml of COVID-19 convalescent plasma (CCP) was collected from recovered individuals in each group by two different cell separators. The overall donor's attendance rate, deferral rate, adverse events and donor compliance was analysed and compared between the two groups.

Results

There was a significant difference in attendance in relation to registration between the groups (P < 0·0001). Donor deferral was significantly higher in group II compared with group I. The single most frequent cause of donor deferral was low antibody index (P = 0·0001). The total donor adverse event rate in CCP donation was significantly lower compared with routine plateletpheresis procedures. The donor's compliance to blood centre's protocol was satisfactory in both the groups.

Conclusion

Recruitment of patients in the post-COVID-19 follow-up in the clinic was more effective than the general recruitment through mass and electronic media for convalescence plasma donation in a resource-constrained blood centre.

Use of therapeutic plasma exchange in heparin-induced thrombocytopenia: A population-based study

BACKGROUND

Heparin-induced thrombocytopenia (HIT) is characterized by anti-heparin/platelet factor 4 immune complexes, which are removed by therapeutic plasma exchange (TPE). Our main objective was to study TPE outcomes in HIT using a large administrative claims database.

STUDY DESIGN AND METHODS

We used the National Inpatient Sample (NIS) to identify hospital discharges of adult patients (≥18) with a primary or secondary diagnosis of HIT. Cases were classified into two groups based on TPE use. The primary outcome was in-hospital mortality. Secondary outcomes were thrombotic events, major bleeding, hospital length of stay (LOS), and charges. Multivariable regression analysis, controlling for age and medical comorbidities, was used to examine the association of TPE with study outcomes.

RESULTS

A HIT diagnosis was made in 22 165 discharges, of which 90 (0.4%) received TPE. Corresponding national estimates are 106 435 and 439, respectively. TPE was not associated with decreased in-hospital mortality (OR = 1.72; 95%CI: 0.93-3.17, P = .085). However, TPE was associated with a higher likelihood of major bleeding (OR = 2.35; 95%CI: 1.40-3.68, P = .0009), primarily driven by gastrointestinal bleeding (OR = 2.21; 95%CI: 1.17-4.17, P = .015). TPE was also associated with higher hospital LOS (20.5 vs 10 day, P < .0001) and charges (USD 211181 vs USD 81654, P < .0001).

CONCLUSION

TPE's association with increased bleeding and a prolonged hospital course indicates that it is being used in HIT cases with a severe clinical phenotype. Future studies are needed to better characterize the HIT phenotype that will most benefit from TPE.

Plasmapheresis for the management of acute cyanide poisoning: A case report and review of literature

In case of mild to moderate cyanide poisoning, especially when standard antidote kits are not readily available, plasmapheresis can be utilized as an alternative option alongside supportive measures.

Successful treatment of plasmapheresis followed by interferon beta-1a in a child with severe COVID-19

COVID-19 outbreak has become a global health concern due to challenges in treatment and high mortality rate; therefore, its therapeutic approaches play an important role in reducing the mortality rate and resolving this concern. Different therapies have been introduced, including interferon beta-1a and purification methods, for instance, plasmapheresis. In this article, we reported a child with severe COVID-19 who fully recovered after receiving plasmapheresis and interferon beta-1a.

Anti-glomerular basement membrane disease associated with thin basement membrane nephropathy: A case report

RATIONALE

Simultaneous occurrence of anti-glomerular basement membrane (anti-GBM) disease and thin basement membrane nephropathy (TBMN), both of which invade the type IV collagen subunits, is very rare. Here, we present the case of a 20-year-old male patient diagnosed with both anti-GBM disease and TBMN upon presenting dyspnea and hemoptysis.

PATIENT CONCERNS

No laboratory abnormalities, except arterial hypoxemia (PaO275.4 mmHg) and microscopic hematuria, were present. Chest computed tomography revealed bilateral infiltrations in the lower lung fields; thus, administration of empirical antibiotics was initiated. Gross hemoptysis persisted nonetheless, and bronchoscopy revealed diffuse pulmonary hemorrhage with no endobronchial lesions. Broncho-alveolar lavage excluded bacterial pneumonia, tuberculosis, and fungal infection.

DIAGNOSIS

Enzyme-linked immunosorbent assay of his serum was positive for anti-GBM antibody (95.1 U/mL). Human leukocyte antigen (HLA) test was positive for both HLA-DR15/-DR04. Other than diffuse thinning of the GBM (average thickness, 220 nm), index kidney biopsy did not demonstrate any specific abnormalities such as crescent formation.

INTERVENTIONS

Methylprednisolone was administered intravenously for 7 consecutive days (500 mg/day), followed by the daily dose of oral prednisolone (80 mg). Cyclophosphamide was also orally administered every day for 3 months (250 mg/day). Following 6 sessions of plasmapheresis, the anti-GBM antibody in serum became negative.

OUTCOMES

There was no clinical evidence suggesting recurrence of pulmonary hemorrhage or azotemia during hospitalization and 12-month follow-up period. Twelve months after hospital discharge, oral prednisolone was discontinued.

LESSONS

The patients with concurrent anti-GBM disease and TBMN will have a favorable prognosis after proper therapy. However, further research is needed to elucidate the pathogenesis and long-term outcome of the comorbidity of these 2 diseases.

Clinical characteristics, triggering etiologies, and response of plasmapheresis in thrombotic microangiopathy in Taiwan

Thrombotic microangiopathy (TMA) syndromes are extraordinarily diverse in clinical presentations and etiologies. However, there are still a limited number of large cohort studies focusing on the underlying causes, outcomes, and response to plasmapheresis.A retrospective study was designed to understand trigger etiologies, organ dysfunctions, clinical outcomes, and efficacy of plasmapheresis in patients with TMA. The whole population of Taiwan was set up into 2 cohorts: 875 patients with TMA in the 2006 cohort (2006-2010) and 1352 patients with TMA in the 2011 cohort (2011-2015). One hundred ninety-five patients in the 2006 cohort and 272 patients in the 2011 cohort were under plasmapheresis treatment.The common underlying etiologies were pregnancy, followed by systemic lupus erythematosus, rheumatoid arthritis, transplantation and drugs, which were significantly higher than the control group. Stroke, seizure, arterial thrombosis, vascular stenosis, hypertension, myocardial infarction, and pancreatitis were the main clinical signs and extra-renal involvements. In the multivariate regression analysis, stroke, arterial thrombosis, peripheral arterial disease, and uremia were significantly higher compared with the control group. The mortality rate in TMA under plasmapheresis was significantly higher than all TMA cases (39.33% vs 15.39% in the 2006 cohort and 39.27% vs 15.06% in the 2011 cohort).This study indicated the spectrum of underlying causes, extra-renal characteristics, and the response to plasmapheresis of patients with TMA in Taiwan. Of note, the poor clinical outcomes of plasmapheresis in patients with TMA might highlight the masked underlying etiology or worse disease condition that should be noticed.

A Fatal Case of Hypertriglyceridemia-Induced Acute Pancreatitis in a Patient With Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) with coexisting hypertriglyceridemia-induced acute pancreatitis is a rare yet potentially life-threatening condition. This report describes a patient with no history of diabetes who presented with DKA and coexisting acute pancreatitis secondary to severe hypertriglyceridemia. The patient did not respond to standard DKA management or plasmapheresis, developed acute respiratory distress syndrome (ARDS), and eventually expired. 

Rebound and overshoot of donor-specific antibodies to human leukocyte antigens (HLA) during desensitization with plasma exchanges in hematopoietic progenitor cell transplantation: A case report

BACKGROUND

Donor-specific antibodies (DSA) to HLA have been associated with graft loss in hematopoietic progenitor cell (HPC) transplantation. Limited data associate therapeutic plasma exchange (TPE) with desensitization and successful engraftment. We report an attempt of desensitization and observed overshooting of DSA during transplantation.

CASE REPORT AND RESULTS

A 27-year-old female with cutaneous T cell lymphoma was scheduled for HPC transplantation from her HLA-haploidentical half-sister, who carried the HLA-DRB1*13:03:01 allele. The patient had the corresponding DSA. Lacking an alternative donor option at the time, we attempted a desensitization approach by immunosuppression with tacrolimus and mycophenolate mofetil (MMF). Unexpectedly, DSA increased from a mean fluorescence intensity (MFI) of 1835 on day -63 to 9008 on day -7. The MFI increased further during 3 TPE procedures and intravenous immunoglobulin (IVIG) until day -1. After transplantation, the DSA remained elevated despite 2 more TPE/IVIG procedures and graft-versus-host disease prophylaxis with high-dose cyclophosphamide, sirolimus, and MMF. Flow cytometric crossmatch, initially negative, turned positive after transplantation. Primary graft failure occurred and was attributed to antibody-mediated rejection. A second transplantation from a 7/8 HLA-matched unrelated donor, not carrying DRB1*13:03 allele, resulted in successful engraftment.

CONCLUSION

Unexpected and rapid increases of a DSA can occur despite the use of current desensitization approaches. This is problematic when conditioning has already started, as such increases are unlikely to be overcome by TPE or other interventions for desensitization. Overshoot of DSA in HPC transplantation has rarely been reported. Its cause remains unclear and can include underlying disease, immunotherapy, chemotherapy, or TPE.

Personalized collection of plasma from healthy donors: A randomized controlled trial of a novel technology-enabled nomogram

Background

Source plasma is essential to support the growing demand for plasma‐derived medicinal products. Supply is short, with donor availability further limited by the coronavirus disease 2019 (COVID‐19) pandemic. This study examined whether a novel, personalized, technology‐based nomogram was noninferior with regard to significant hypotensive adverse events (AEs) in healthy donors.

Study Design and Methods

IMPACT (IMproving PlasmA CollecTion) was a prospective, multicenter, double‐blinded, randomized, controlled trial carried out between January 6 and March 26, 2020, in three U.S plasma collection centers. Donors were randomly assigned to the current simplified 1992 nomogram (control) or a novel percent plasma nomogram (PPN) with personalized target volume calculation (experimental). Primary endpoint was the rate of significant hypotensive AEs. Noninferiority (NI) was tested with a margin of 0.15%. Collected plasma volume was a secondary endpoint.

Results

A total of 3443 donors (mean [SD] BMI: 32 [7.74] kg/m²; 65% male) underwent 23,137 donations (median [range]: 6 [1–22] per subject). Ten significant hypotensive AEs were observed (six control; four experimental), with model‐based AE incidence rate estimates (95% CI) of 0.051% (0.020%–0.114%) and 0.035% (0.010%–0.094%), respectively (p = .58). NI was met at an upper limit of 0.043% versus the predefined margin of 0.15%. There was no statistical difference between total AEs (all AE types: p = .32). Mean plasma volume collected was 777.8 ml (control) versus 841.7 ml (experimental); an increase of 63.9 ml per donation (8.2%; p < .0001).

Conclusion

This trial showed that a novel personalized nomogram approach in healthy donors allowed approximately 8% more plasma per donation to be collected without impairing donor safety.

A Case of Severe Refractory Pemphigus Vulgaris in a Patient With Stable Esophageal Malignancy

Pemphigus is a broad term that is used to describe a group of bullous autoimmune diseases affecting the skin and mucous membranes; the pathogenesis involves autoantibodies directed against various cell junction desmosomal proteins. In patients with a history of malignancy who present with bullous lesions, the differential diagnosis may include, but is not limited to, paraneoplastic pemphigus (PNP) and pemphigus vulgaris (PV) secondary to a primary autoimmune process, or induced by chemotherapy or radiation therapy. In this report, we present a case of refractory PV in a patient with stable esophageal cancer, five years after undergoing radiation therapy. He was poorly responsive to corticosteroids and intravenous immunoglobulin (IVIG). PNP or PV in a patient with stable esophageal malignancy has not been previously reported. PNP and PV can have overlapping autoantigens [desmoglein types 1 and 3 (DSG1 and DSG3)] as well as similar presentations. Thus, distinguishing between the two may be challenging in a patient with a history of cancer. More research must be done to determine if PNP can be seen in a patient with stable esophageal malignancy and, similarly, if PV can be precipitated by stable esophageal malignancy. Such research would aid in determining whether or not similar presentations are more severe or refractory to standard treatment regimens, thereby contributing to improve treatment strategies.

Lupus Cerebritis Refractory to Guideline-Directed Therapy: A Case Report

Systemic lupus erythematosus is an autoimmune disease that affects multiple organs and organ systems, subsequently requiring an elaborate regimen for management. We present the case of a 63-year-old female who developed unrelenting symptoms of drug-induced lupus, which persisted even after the offending agent was withdrawn, unmasking her underlying systemic lupus erythematosus. She continued to develop neuropsychiatric symptoms, including mania and hallucinations, which complicated the management of her disease. After exhausting the bank of anti-inflammatory and immunomodulators recommended by current guidelines, we found that a combination of rituximab infusions with thiothixene, an antipsychotic agent, significantly improved our patient’s neuropsychiatric symptoms. Further research should be conducted to determine the efficacy of rituximab in the treatment of resistant lupus cerebritis, and to validate the use of thiothixene in the management of neuropsychiatric symptoms secondary to lupus.

Case Report: Blurred Vision and Eruptive Nevi - Bilateral Diffuse Uveal Melanocytic Proliferation With Mucocutaneous Involvement in a Lung Cancer Patient

We describe a case of a 65-year old patient presenting with unusual mucocutaneous melanocytic proliferations of a Bilateral Diffuse Uveal Melanocytic Proliferation (BDUMP) imitating a multifocal melanoma in situ, which improved dramatically after plasmapheresis. The patient first presented at the dermatology department due to rapidly evolving brown and black macules on the glans penis. Further skin involvement of the perineal and perianal region, mamillae and oral mucosa was stated. Histology from a penile biopsy was compatible with a melanoma in situ. Due to the distribution pattern and elevated serum tumor marker S100B, metastatic melanoma was considered. Staging examinations using PET-CT scan however, revealed a lung tumor, later confirmed as a Non-small-cell lung cancer (NSCLC). Primary radio chemotherapy was initiated to treat NSCLC. Shortly after initiation of radio chemotherapy the patient developed massive vision impairment and a NSCLC-associated BDUMP was diagnosed which led to the correct classification of melanocytic skin lesions as mucocutaneous BDUMP manifestation. Plasmapheresis was started resulting in a rapid improvement of vision starting ten days after the first plasmapheresis. In contrast skin manifestations started to disappear with a marked delay 4 months after the last plasmapheresis cycle. This case highlights the importance of memorizing multiple rapidly progressing melanocytic skin and/or mucous membrane spots together with visual impairment as a possible paraneoplastic BDUMP that needs a fundamentally different therapeutic approach compared to multifocal melanoma in situ. What is already known about this topic? Bilateral Diffuse Uveal Melanocytic Proliferation (BDUMP) is a paraneoplastic syndrome with melanocytic uveal proliferation leading to vision impairment. Extraocular manifestation is rare, mainly affect the subepidermal compartment and is hard to treat. Plasmapheresis has been shown to be an effective treatment mainly for vision improvement in some but not all cases. What does this study add? Our BDUMP case with widespread skin and mucosal involvement initially mimicked a multifocal melanoma in situ and showed an excellent treatment response to plasmapheresis. Improvement of mucocutaneous lesions has not been documented well in the literature so far. We show a more than one year lasting follow up still underlining the beneficial effect of plasmapheresis in this case. In-vitro data supports the hypothesis that plasma exchange eliminates a "Cultured melanocyte elongation and proliferation (CMEP)" factor out of patient blood leading to decreased melanocyte proliferation shown numerically in-vitro and clinically in-vivo. Our case clearly indicates that before establishing a definite diagnosis and therapy in patients with rapidly evolving melanocytic skin and/or mucosal lesions BDUMP mimicking multifocal melanoma in situ should be considered making a thorough diagnostic workup mandatory.

Abdominal Pain as the Manifestation of Chylomicronemia Syndrome During Pregnancy: A Challenging Diagnosis

Hypertriglyceridemia is a frequent cause of acute pancreatitis. Levels higher than 1000 mg/dL are often associated with a genetic predisposition that can be aggravated by other factors such as pregnancy and poorly controlled diabetes. The authors report a 19-year-old primigravida that presented with abdominal pain, emesis and a pruritic rash, along with severely increased plasma triglyceride levels. Therapeutic plasmapheresis was proposed in the setting of a presumed acute pancreatitis. Chylomicronemia syndrome is a rare and frequently misdiagnosed pathology that can evolve with abdominal pain, vomiting and a specific cutaneous rash designated as eruptive xanthomatosis. This case report illustrates the challenges of achieving a correct diagnosis for rare conditions and corroborates the safety of plasmapheresis during pregnancy.

Multidisciplinary management of anti-PP1Pk or anti-P alloimmunization during pregnancy: A new case with anti-P and a literature review

BACKGROUND

Red blood cell alloimmunization is the first cause of fetal and neonatal anemia. Alloimmunizations with anti-PP1P^k or anti-P can cause recurrent miscarriages and hemolytic disease of the fetus and newborn in the 2nd and 3rd trimesters of pregnancy. We report on a pregnant patient immunized with anti-P and a history of recurrent miscarriages.

CASE REPORT

This P₂ ^k (GLOB:-1; P1PK:-1,3) patient had a first pregnancy marked by a caesarean at 38 weeks of gestation (WG) for non-reassuring fetal heart rate. Then, she had three early spontaneous miscarriages. The fifth pregnancy began with a high titer of anti-P at 128. Early initiation of treatment with Intravenous Immunoglobulins (IVIg) and plasma exchanges (PE) starting at 5 WG permitted us to reduce the titer of anti-P below 32. A healthy infant was delivered by caesarean at 38 WG without anemia at birth and no exchange transfusion was required.

DISCUSSION AND REVIEW OF THE LITERATURE

The P and P^k antigens are expressed on placental, trophoblastic, and embryonic cells. This explains why P₁ ^k (GLOB:-1; P1PK:1,3), P₂ ^k (GLOB:-1; P1PK:-1,3), or Tj(a-)/p (GLOB:-1; P1PK:-1,-3) patients are prone to recurrent abortions in the first trimester of pregnancy. A literature review demonstrated 87% (68/78) of miscarriages in p patients. However, publication biases are possible with the most severe cases being reported.

CONCLUSION

Immunizations to P and PP1P^k antigens differ from others in their physiopathology and precocity. The association of PE and IVIg seems to be an effective treatment in the management of anti-PP1P^k or anti-P fetomaternal incompatibilities.

An Unusual Case of Candida kefyr Fungemia in an Immunocompromised Patient

An immunocompromised patient with a known history of cerebrovascular accident (CVA) with right-sided hemiparesis of long duration, type 2 diabetes mellitus, and hypertension presented with signs of rhabdomyolysis and later acute kidney injury (AKI). He subsequently developed Guillain Barre syndrome. Initially, hemodialysis was followed by plasmapheresis. After hemodialysis, the patient presented with multiple episodes of vomiting and weakness of all limbs. A culture showed growth of Enterococcus faecalis, and on Day 6, a bloodstream infection with Candida kefyr and a urinary tract infection with Enterococcus faecalis were diagnosed. We report a rare case of bloodstream infection due to C. kefyr.

Severe L-asparaginase-induced Hypertriglyceridaemia Treated with Plasmapheresis

L-asparaginase is used for the treatment of acute lymphoblastic leukaemia. Hypertriglyceridaemia is a side effect and associated with potentially fatal complications, including acute pancreatitis. Plasmapheresis may have a role in treatment when triglycerides are >2000 mg/dl. We report the case of a 39-year-old woman treated with L-asparaginase for acute lymphoblastic leukaemia, who developed severe hypertriglyceridaemia (6560 mg/dl) and acute pancreatitis. Intravenous insulin infusion was started, along with fenofibrate and atorvastatin administration, and platelet transfusion. Plasmapheresis was carried out leading to a frank decline in serum triglyceride levels (366 mg/dl), a decrease in pancreatic enzymes and clinical improvement. The diagnosis of pancreatitis secondary to L-asparaginase should lead to immediate drug withdrawal, and plasmapheresis should be considered when serum triglyceride values exceed 2000 mg/dl. In our case, there was a 95% triglyceride removal rate. This response illustrates the strong effectiveness of early treatment with plasmapheresis in severe and symptomatic hypertriglyceridaemia associated with L-asparaginase.

LEARNING POINTS

Pancreatitis following L-asparaginase-induced hypertriglyceridaemia is a severe and potentially reversible condition in both adults and children treated for acute lymphoblastic leukaemia.Early plasmapheresis is more effective to rapidly decrease serum triglycerides.

Apheresis Efficacy and Tolerance in the Setting of HLA-Incompatible Kidney Transplantation

Nearly 18% of patients on a waiting list for kidney transplantation (KT) are highly sensitized, which make access to KT more difficult. We assessed the efficacy and tolerance of different techniques (plasma exchanges [PE], double-filtration plasmapheresis [DFPP], and immunoadsorption [IA]) to remove donor specific antibodies (DSA) in the setting of HLA-incompatible (HLAi) KT. All patients that underwent apheresis for HLAi KT within a single center were included. Intra-session and inter-session Mean Fluorescence Intensity (MFI) decrease in DSA, clinical and biological tolerances were assessed. A total of 881 sessions were performed for 45 patients: 107 DFPP, 54 PE, 720 IA. The procedures led to HLAi KT in 39 patients (87%) after 29 (15–51) days. A higher volume of treated plasma was associated with a greater decrease of inter-session class I and II DSA (p = 0.04, p = 0.02). IA, PE, and a lower maximal DSA MFI were associated with a greater decrease in intra-session class II DSA (p < 0.01). Safety was good: severe adverse events occurred in 17 sessions (1.9%), more frequently with DFPP (6.5%) p < 0.01. Hypotension occurred in 154 sessions (17.5%), more frequently with DFPP (p < 0.01). Apheresis is well tolerated (IA and PE > DFPP) and effective at removing HLA antibodies and allows HLAi KT for sensitized patients.

Preoperative plasmapheresis in patients with Graves' disease intolerant to antithyroid drugs

Antithyroid drugs (ATDs) are the mainstay of treatment for Graves' disease with possible detrimental adverse effects. Surgery or radioactive iodine (RAI) ablation is the second choice among the treatment options in cases of non-remission. Normalization of serum thyroid hormone levels as much as possible is required before surgery or RAI to prevent thyrotoxic crisis in patients with uncontrolled Graves' disease. In recent decades, therapeutic plasma exchange (TPE) has been used in the treatment of thyroid storm, drug-induced hepatotoxicity and agranulocytosis, or patients with hyperthyroidism scheduled for emergency surgery. TPE is an effective method to reduce serum FT3, FT4, and TRAB levels in severe hyperthyroid conditions. Although TPE-related complications are rare, the risk of bleeding needs to be taken into consideration in patients who were scheduled for surgery within 24 h after TPE. In terms of reducing intraoperative bleeding, patients can be referred to surgery 24-48 h after TPE, or fresh frozen plasma transfusion can be the preferred treatment for emergency cases.