Plasmapheresis. Technical aspects and indications

Risk Factors and Clinical Outcomes of Renal Thrombotic Microangiopathy in Children with Lupus Nephritis in Terms of Pathological and Clinical Features

BACKGROUND

Thrombotic microangiopathy (TMA) is an important risk factor for the prognosis of lupus nephritis (LN). Patients with LN complicated with TMA tend to be critically ill with high mortality and poor prognosis. In the present study, we retrospectively analyzed the clinical manifestations, laboratory results, renal pathological manifestations, and prognosis of children with LN-TMA and analyzed the risk factors for end-stage renal disease (ESRD) in children with LN-TMA.

METHODS

Seventy-four patients with LN and renal TMA (rTMA) were selected and compared to 128 LN controls without TMA (1:2 ratio) matched according to demographics, pathological type and treatments.

RESULTS

The mean values of systolic blood pressure, diastolic blood pressure (DBP), lactate dehydrogenase (LDH), blood urea nitrogen (BUN), urinary protein quantitation (PRO), urine red blood cells, N-acetyl-β-D-glucosidase (NAG), retinol-binding protein, systemic lupus erythematosus disease activity score (SLEDAI), and activity index (AI) scores in the TMA group were all higher than those in the non-TMA group (p < 0.05 and p < 0.01). The mean values of complement C3, hemoglobin, platelets, estimated glomerular filtration rate, and chronic index (CI) score in the TMA group were all lower than those in the non-TMA group (p < 0.05 and p < 0.01). The number of cases of glomerular crescent, fibrous crescent, endocapillary proliferation, tubular atrophy, interstitial fibrosis, C3 and C1q deposition in the TMA group was higher than that in the non-TMA group (p < 0.05 and p < 0.01). The 3-year and 5-year renal survival rates in the TMA group (88.93% vs. 97.00%, p < 0.05) and TMA group (61.41% vs. 82.31%, p < 0.05) were significantly lower than those in the non-TMA group. Multivariate Cox regression analysis showed that serum creatinine before treatment (≥110 μmol/L), TMA and interstitial fibrosis were independent risk factors for the development of ESRD in LN children.

CONCLUSION

The general condition of children with TMA is critical, and the prognosis is poor. Early detection, early treatment and the development of new treatments are key to improving LN-TMA outcomes in children.

A Neonate With Cytokine Storm Managed With Steroids, Therapeutic Plasma Exchange, and Tocilizumab

Neonatal cytokine storms, though rare, can induce hyperinflammation due to elevated interleukin-6 (IL-6), triggering multiorgan failure. We present the case of a term male neonate necessitating extracorporeal membrane oxygenation (ECMO) post-birth for persistent pulmonary hypertension due to meconium aspiration syndrome. Three days after weaning from ECMO support, steroids and therapeutic plasma exchange were initiated due to deteriorating thrombocytopenia, oxygenation, hemodynamic instability, and increased C-reactive protein (CRP) and ferritin levels. Elevated IL-6 prompted tocilizumab administration after four days of daily plasmapheresis. Post-tocilizumab infusion, notable enhancements in platelet counts, oxygenation indices, and CRP were observed, resulting in stable discharge of the child. Comprehensive evaluations for infections, including coronavirus disease 2019, as well as genetic and metabolic disorders, yielded negative results.

Plasma exchange as an adjunctive therapy in anti-neutrophil cytoplasm antibody-associated vasculitis

INTRODUCTION

We summarize evidence for the role of therapeutic plasma exchange (TPE) in the treatment of anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). TPE rapidly removes ANCA IgG, complement and coagulation factors important in the pathogenesis of AAV. TPE has been used in patients with rapidly deteriorating renal function to achieve early disease control, allowing time for immunosuppressive agents to prevent resynthesis of ANCA. The PEXIVAS trial challenged the utility of TPE in AAV, as it did not show benefit of adjunctive TPE on a combined end point of end stage kidney disease (ESKD) and death.

AREAS COVERED

We analyze data from PEXIVAS and other trials of TPE in AAV, an up-to-date meta-analysis, and recently published large cohort studies.

EXPERT OPINION

There remains a role for the use of TPE in AAV in certain groups of patients, in particular those with severe renal involvement (Cr >500 μmol/L or dialysis-dependent). It should be considered in patients with Cr >300 μmol/L and rapidly deteriorating function, or with life-threatening pulmonary hemorrhage. A separate indication is patients double positive for anti-GBM antibodies and ANCA. TPE may have the greatest benefit as part of steroid-sparing immunosuppressive treatment strategies.

Fabrication and Separation of EGaIn Microparticles from Human Blood Based on Dielectrophoresis Force and a W-Type Electrode

Harmful particles such as heavy metal particles in the human body can cause many problems such as kidney stones, gallstones, and cerebrovascular diseases. Therefore, it is critical to separate them from the blood and perform a systematic analysis as early as possible. Here, we apply eutectic gallium indium (EGaIn) microparticles as a model to study the separation of particles from blood, thanks to their properties of low toxicity, excellent degradability, and negligible vapor pressure. In particular, the dielectrophoresis (DEP) separation method is employed to separate EGaIn of different sizes and characteristics in blood. First, the screen-printing method is used to create EGaIn microparticles with diameters of 15, 23, 18, and 11 μm. According to the lifetime test, these microparticles can last more than 1 month, as evidenced by their surface oxidation characteristics. Moreover, a DEP platform with W-type electrodes is developed to sort EGaIn particles from whole human blood. The results show that a sorting efficiency of 95% can be attained, which is similar to the separation efficiency of 98% achieved by finite element analysis (FEA) using COMSOL software based on the orthogonal array experiment method. The proposed study successfully validates the use of the DEP method to separate particles from human blood, providing insights into heavy metal particle separating, drug screening, and cell sorting and potentially broadening the applications in environmental analysis, food engineering, and bioengineering.

Cost-minimisation analysis of plasma exchange versus IVIg in the treatment of autoimmune neurological conditions

Background

Plasma exchange (PLEX) is an effective treatment for antibody-mediated neurological disorders and has been shown to be equally efficacious to intravenous immunoglobulin (IVIg) with comparable adverse event profiles. IVIg has traditionally been the preferred treatment option due to its ease of use. However, advancing technology has allowed PLEX to be performed with a centrifugal system via peripheral access as opposed to central access via a membrane filter.

Methods

We prospectively collected data from a cohort of patients who underwent PLEX at the Wessex Neurological Centre, UK, to perform a cost-minimisation analysis comparing PLEX to IVIg, the standard of care, between May 2019 and May 2020. Data obtained included indication, admission type (inpatient, daycase or intensive care), access (peripheral or central), number of PLEX cycles, exchange volume, patient weight, complications and clinical outcomes. The cost of PLEX delivered in an outpatient setting for an average 80kg person was calculated and compared to the equivalent cost of delivering IVIg by means of a cost-minimization model.

Results

The provision of PLEX was roughly half as costly when compared to what it would have been for IVIg (£886 per exchange vs £1778 per infusion or £4432 per cycle of 5 exchanges vs £8890 per cycle of 5 infusions). Our cohort included a total of 44 patients who received a total of 357 PLEX exchanges during the 12-month period (the majority of which were in a daycase setting). We calculated an annual cost saving for PLEX over IVIg of £318,589. The robustness of this result was confirmed by a one-way deterministic sensitivity analysis, showing the cost-effectiveness of PLEX.

Conclusion

Our findings demonstrate that PLEX is more cost-effective than IVIg in this setting. Our study supports the economic case for development of plasma exchange centres in regional neurology units, a case made all the more relevant in the context of constrained supplies of IVIg.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08210-z.

A Case of Bilateral Diffuse Uveal Melanocytic Proliferation in the Setting of Urothelial Carcinoma of the Ureter: A Failed Response to Plasmapheresis

Bilateral diffuse uveal melanocytic proliferation (BDUMP) is a rare paraneoplastic syndrome. Diagnosis can be difficult and treatment guidelines are ill-defined. A 73-year-old man with poorly differentiated high grade urothelial carcinoma of the ureter metastatic to the liver, lungs, lymph nodes, and pelvis treated with chemotherapy and immunotherapy reported gradual vision loss. Optical coherence tomography (OCT) demonstrated intraretinal and subretinal fluid with hyperreflective subretinal deposits and focal, deeply pigmented choroidal lesions. Irregular hyperpigmentation of the retinal pigment epithelium (RPE) with a "leopard spot" pattern on fundus autofluorescence (FAF) supported the diagnosis of BDUMP. Multiple plasmapheresis sessions did not result in sustained clinical improvement. [Ophthalmic Surg Lasers Imaging Retina 2022;53(6): 350-353.].

Application of Extracorporeal Apheresis in Treatment of COVID-19: a Rapid Review

Spread of a novel coronavirus infection in 2019 caused by SARS-CoV-2 virus has become a real threat to public health all around the world. The new pandemic required the mobilization of all resources for effective treatment of COVID-19 patients. Extracorporeal apheresis methods were suggested as an addition to the therapy of severe COVID-19 patients, especially when there is a threat of cytokine storm. Cytokine storm has a complex and not fully understood mechanism, and it can result in the multiple organ failure syndrome, associated with high mortality. The main cytokines that play the key role in the cytokine storm are IL-6, IL-10, and TNF-alpha. Removal of the target pro-inflammatory cytokines from the bloodstream can be beneficial in reducing the risk of complications as well as the mortality rate. We describe and compare different methods of extracorporeal apheresis: hemoadsorption, selective plasma filtration, and plasma exchange therapy in the context of their potential use in COVID-19 treatment.

Tolerance and complications of therapeutic plasma exchange by centrifugation: A single center experience

INTRODUCTION

Therapeutic plasma exchange (TPE) constitutes an important therapy for hematological, neurological, immunological, and nephrological diseases. Most studies have focused on efficacy, whereas tolerance and complications during sessions have been less well studied and not recently.

MATERIAL AND METHODS

We conducted a single center retrospective study of all patients who underwent TPE between 2011 and 2018. TPE sessions using the centrifugation technique were performed by dedicated trained nurses. Specific side effects were identified through surveillance forms completed contemporaneously. The primary outcome was the rate of all-type adverse effects that occurred during the TPE sessions.

RESULTS

In total, 1895 TPE sessions performed on 185 patients were analyzed. At least one adverse effect was reported for 805 sessions (42.5% [29.9%-70.1%]), corresponding to 171 patients (92.4% [87.6%-95.8%]). Hypotension occurred during 288 sessions (15.2%), was asymptomatic in 95.8% of cases, and more frequent with the use of 4% albumin than fresh frozen plasma (FFP) (19.8 vs 8.9%, P <.0001). Hypocalcemia occurred during 370 sessions (19.6%) and was more frequent with the use of FFP than with the use of albumin alone (FFP alone: 28.0%, albumin + FFP: 26%, albumin alone: 11.7%; P <.0001). Allergic reactions occurred during 56 sessions (3%), exclusively with FFP. Severe adverse effects were reported for 0.3% of sessions and 5.4% of patients.

CONCLUSIONS

TPE is a safe therapy when performed by a trained team. Adverse effects were frequent but mostly not serious. The replacement fluid was the main determinant of the occurrence of complications. (ClinicalTrials.gov ID: NCT03888417).

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.

Outcome of therapeutic plasma exchange in Myasthenia gravis patients

Aims:

The aim of this study was to evaluate the indications, adverse reactions, and outcome of therapeutic plasma exchange (TPE) in myasthenia gravis (MG) patients.

Settings and Design:

Retrospective Observational study.

Methods and Material:

A total of 18 patients of MG had undergone 18 cycles and 87 session of TPE at our Institution, a tertiary care center in Western India. It was performed using a single volume plasma exchange with intermittent cell separator (Freseniouscomtec), subclavian central line access, and with alternate day interval. Outcome was assessed shortly after each session and overall outcome at the time of discharge.

Results:

Total of 68 patients of MG were admitted to Neurology Intensive care unit (ICU) during the study period [January 2016–December 2019]. Out of them, TPE was done in 18 patients. Among the 18 patients, 11 patients had myasthenic crisis and 7 patients had worsening of MG. The mean number of TPE session was 4.2(SD ± 1.2), volume exchange was 2215 ml (SD ± 435); overall incidence of adverse reaction was 33.3%. All patients had immediate benefits of each TPE cycle. Good acceptance of procedure was observed in 72.2% of patients.

Conclusions:

TPE is cost-effective rapid therapy for myasthenic crisis and progressive myasthenia gravis. It reduces ICU stays and improves outcome.

Prospects of plasmapheresis for patients with severe COVID-19

On February 11, 2020, the World Health Organization officially named the infection caused by the new coronavirus "Coronavirus disease 2019" (COVID-19). On February 11, 2020, the International Committee on Taxonomy of Viruses (ICTV) officially named the infectious matter "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2). Emergence of severe complications with new coronavirus disease is due to the development of hypercytokinaemia, also known as "cytokine storm". These complications comprise acute respiratory distress syndrome (ARDS), respiratory failure and death. Emerging data point to the logic of using extracorporeal haemocorrection to normalise cytokine levels and reduce the severity of organ disorders. The analysis of the literature indicates that to date, a certain positive experience has been accumulated in the world in the application of extracorporeal methods in clinical practice in patients with COVID-19.

Efficacy of Plasmapheresis and Immunoglobulin Replacement Therapy (IVIG) on Patients with COVID-19

Since the rapidly evolving outbreak of COVID-19, several empirical therapeutic options have been recommended including the use of antivirals, steroids, and vaccines. According to recent observations about different modalities in treatment of patients infected with COVID-19, plasmapheresis and intravenous immunoglobulin (IVIg) have been reported to be an effective empirical therapeutic option to control the infection. In this review, we aimed to provide an overview on the possible application of plasmapheresis and intravenous immunoglobulin in patients with COVID-19.

Therapeutic Efficacy of Plasma Exchange in Neuromyelitis Optica

Background

Neuromyelitis optica (NMO) is an inflammatory demyelinating disease that selectively affects the optic nerves and spinal cord and generally follows a relapsing course. Therapeutic plasma exchange (TPE) appears to be effective in patients with central nervous system inflammatory demyelinating disease who do not respond to first-line corticosteroid treatment.

Objective

We represent a retrospective review of the use of TPE in the treatment of an acute attack of NMO in five patients who failed to respond to initial immunomodulatory treatment.

Materials and Methods

We evaluated the effect of TPE on the degree of recovery from NMO. It was performed using a single volume plasma exchange with intermittent cell separator (Hemonetics Mobile Collection System plus) by femoral or central line access and scheduled preferably on alternate-day intervals from 8 to 10 days. Both subjective and objective clinical response to TPE was estimated, and final assessment of response was made at the time of the last TPE in the series.

Results

All patients were severely disabled before the initiation of TPE and they were female; with the mean age of these patients was 52.5 years (range = 36-69 years), the median age of NMO diagnosis was 49.4 years (range = 35-65 years), and the median duration of disease was 2.6 years (range = 0-5 years). Out of five patients, three had a history of bilateral optic neuritis, and all patients were anti-against protein aquaporin-4antibody positive. Totally 24 TPE procedures were performed on five patients, the mean time of start of TPE in the acute attack was 18.6 days. Patients were severely disabled at the initiation of TPE (range = expanded disability status scale 6.5-9), and improvement was observed early in the course of TPE treatment in most patients.

Conclusion

The present study provides clinical support for the importance of TPE in refractory acute attack in NMO. However, with new diagnostic technologies and increasing clinical awareness, we may see a more improved ways of TPE in these patients in the future; hence, TPE is more effective modality of treatment as it also removed the antibodies.

Therapeutic plasma exchange in rheumatic diseases: a university hospital experience

INTRODUCTION

Each day, evidence accumulates related to the use of therapeutic plasma exchange (TPE) in patients with rheumatic diseases. San Ignacio University Hospital has recorded all of the TPE sessions performed by the institution's apheresis group.

OBJECTIVE

To describe the TPE experience of patients with rheumatologic diseases in a hospital setting.

METHODS

Descriptive, observational, retrospective analysis. This study included analyses of the TPE sessions that were performed in patients with rheumatic diseases from November 2009 to November 2013.

RESULTS

The apheresis group performed 136 sessions in 27 patients. The mean patient age was 43 years (SD 18.5), and 59.3% of the patients were female. Regarding the diagnosis, the most frequents ones where: ANCA-associated vasculitis followed by systemic lupus erythematosus and catastrophic antiphospholipid syndrome. The average number of sessions per patient was 5 (SD 1.8), and the average plasma exchange per patient was 1.3 plasma volume replacement units. The most used replacement solution was frozen fresh plasma (FFP; 63.2% of the sessions). Of all the sessions, 4.4% presented complications, and the majority of the complications were related to vascular access. Fifteen patients required renal replacement therapy (RRT) secondary to the same cause that created the need for TPE, 3 patients required RRT due to causes other than the TPE diagnostic intervention and 1 patient had undergone chronic dialysis.

CONCLUSIONS

TPE is a therapeutic alternative that is needed for the management of patients with rheumatic diseases with renal involvement and those who are refractory to conventional management. Our clinical results were in agreement with the global literature.

Plasmapheresis and other extracorporeal filtration techniques in critical patients

Plasmapheresis is an extracorporeal technique that eliminates macromolecules involved in pathological processes from plasma. A review is made of the technical aspects, main indications in critical care and potential complications of plasmapheresis, as well as of other extracorporeal filtration techniques such as endotoxin-removal columns and other devices designed to eliminate cytokines or modulate the inflammatory immune response in critical patients.

Use of Cellular and Plasma Apheresis in the Critically Ill Patient: Part II: Clinical Indications and Applications

Apheresis is the process of separating the blood and removing or manipulating a cellular or plasma component for therapeutic benefit. Such procedures may be indicated in the critical care setting as primary or adjunctive therapy for certain hematologic, neurologic, renal, and autoimmune/rheumatologic disorders. In part I of this series, the technical aspects of apheresis were described and the physiologic rationale and clinical considerations were discussed. This review highlights the pathophysiologic basis, specific clinical indications, and treatment parameters for disorders that more commonly require management in the intensive care unit. The choice of plasma or cellular apheresis in these cases is guided by wellaccepted, evidence-based clinical treatment guidelines. For some disorders, such as liver failure, severe sepsis, and multiple-organ dysfunction syndrome, apheresis treatment approaches remain experimental. Ongoing studies are investigating the potential utility of conventional plasma exchange, ex vivo plasma manipulation, and newer technologies for these and other disorders in severely ill patients.

Use of Cellular and Plasma Apheresis in the Critically Ill Patient: Part 1: Technical and Physiological Considerations

Apheresis is the process of separating the blood and removing or manipulating a cellular or plasma component for therapeutic benefit. An apheresis procedure, or series of procedures, may be indicated in the critical care setting as primary or adjunctive therapy for certain hematologic, neurologic, renal, and autoimmune/ rheumatologic disorders. Optimal management of severely ill patients undergoing apheresis requires a working knowledge of the technical, methodological, and therapeutic considerations. These considerations include instrument hardware and separation methods, vascular access requirements, hemodynamic and hemostatic effects of the procedures, exposure to anticoagulants and homologous blood products, physiological variables affecting blood/plasma processing efficiency, and therapeutic endpoints for specific indications. Part 1 of this review will discuss each of those technological considerations and the basic physiological principles that guide this form of therapy. Part 2 of this series will deal with the clinical indications and applications for specific disorders that are most likely to affect patients in the intensive care unit.

[Hyperviscosity syndrome]

Hyperviscosity syndrome is a life-threatening complication. Clinical manifestations include neurological impairment, visual disturbance and bleeding. Measurement of plasma or serum viscosity by a viscometer assesses the diagnosis. Funduscopic examination is a key exam because abnormalities are well-correlated with abnormal plasma viscosity. Etiologies are various but symptomatic hyperviscosity is more common in Waldenström's macroglobulinemia and multiple myeloma. Prompt treatment is needed: treatment of the underlying disease should be considered, but generally not sufficient. Symptomatic measures aim to not exacerbate blood viscosity while urgent plasmapheresis effectively reduces the paraprotein concentration and relieves symptoms.

Therapeutic plasma exchange in the treatment of myasthenia gravis

AIM

The aim of this study was to analyze the retrospective experience related to the indication, complication and outcome of Therapeutic Plasma Exchange (TPE) in Myasthenia gravis (MG). It is a well known autoimmune disease characterized by antibodies against the acetylcholine receptor (anti-ACHR) on the post synaptic surface of the motor end plate. Plasma exchange is the therapeutic modality well established in MG with a positive recommendation based on strong consensus of class III evidence.

MATERIALS AND METHODS

A total of 35 patients of MG were submitted to a total of 41 cycles and 171 session of TPE. It was performed using a single volume plasma exchange with intermittent cell separator (Hemonetics) by Femoral or central line access and schedule preferably on alternate day interval. Immediate outcome was assessed shortly after each session and overall outcome at discharge.

RESULTS

Total of 110 patients of MG who were admitted to our hospital during the study period of two years. 35 (31.8%) patients had TPE performed with mean age of 32 years (M:F = 2:1). The mean number of TPE session was 4.2 (SD±1.2), volume exchange was 2215 ml (SD±435); overall incidence of adverse reaction was 21.7%. All patients had immediate benefits of each TPE cycle. Good acceptance of procedure was observed in 78.3% of patients.

CONCLUSION

TPE may be considered as one of the treatment options especially in developing countries like ours as it is relatively less costly but as effective for myasthenic crisis as other modalities.

Principles and operational parameters to optimize poison removal with extracorporeal treatments

A role for nephrologists in the management of a poisoned patient involves evaluating the indications for, and methods of, enhancing the elimination of a poison. Nephrologists are familiar with the various extracorporeal treatments (ECTRs) used in the management of impaired kidney function, and their respective advantages and disadvantages. However, these same skills and knowledge may not always be considered, or applicable, when prescribing ECTR for the treatment of a poisoned patient. Maximizing solute elimination is a key aim of such treatments, perhaps more so than in the treatment of uremia, because ECTR has the potential to reverse clinical toxicity and shorten the duration of poisoning. This manuscript reviews the various principles that govern poison elimination by ECTR (diffusion, convection, adsorption, and centrifugation) and how components of the ECTR can be adjusted to maximize clearance. Data supporting these recommendations will be presented, whenever available.

Therapeutic plasma exchange as rescue therapy in severe sepsis and septic shock: retrospective observational single-centre study of 23 patients

BACKGROUND

Several case series and small randomized controlled trials suggest that therapeutic plasma exchange (TPE) improves coagulation, hemodynamics and possibly survival in severe sepsis. However, the exact role of TPE in modern sepsis therapy remains unclear.

METHODS

We performed a retrospective observational single-centre study on the use of TPE as rescue therapy in 23 consecutive patients with severe sepsis or septic shock from 2005 to 2012. Main surrogate markers of multiple organ failure (MOF) before, during and after TPE as well as survival rates are reported.

RESULTS

At baseline, mean SOFA score was 13 (standard deviation [SD] 4) and median number of failed organ-systems was 5 (interquartile range [IQR] 4-5). TPEs were performed 3 days (IQR 2-10) after symptom onset and 1 day (IQR 0-8) after ICU admission. The median total exchange volume was 3750 ml (IQR 2500-6000), which corresponded to a mean of 1.5 times (SD 0.9) the individual plasma volume. Fresh frozen plasma was used in all but one treatments as replacement fluid. Net fluid balance decreased significantly within 12 hrs following the first TPE procedure by a median of 720 mL (p = 0.002), irrespective of outcome. Reductions of norepinephrine dose and improvement in cardiac index were observed in individual survivors, but this was not significant for the overall cohort (p = 0.574). Platelet counts decreased irrespective of outcome between days 0 and 2 (p < 0.003), and increased thereafter in many survivors. There was a non-significant trend towards younger age and higher procalcitonin levels among survivors. Nine out of 23 TPE treated patients (39%) survived until ICU discharge (among them 3 patients with baseline SOFA scores of 15, 17, and 20).

CONCLUSIONS

Our data suggest that some patients with severe sepsis and septic shock may experience hemodynamic stabilisation by early TPE therapy.

Available extracorporeal treatments for poisoning: overview and limitations

Poisoning is a significant public health problem. In severe cases, extracorporeal treatments (ECTRs) may be required to prevent or reverse major toxicity. Available ECTRs include intermittent hemodialysis, sustained low-efficiency dialysis, intermittent hemofiltration and hemodiafiltration, continuous renal replacement therapy, hemoperfusion, therapeutic plasma exchange, exchange transfusion, peritoneal dialysis, albumin dialysis, cerebrospinal fluid exchange, and extracorporeal life support. The aim of this article was to provide an overview of the technical aspects, as well as the potential indications and limitations of the different ECTRs used for poisoned patients.

Membrane and centrifugal therapeutic plasma exchange: practical difficulties in anticoagulating the extracorporeal circuit

Therapeutic plasma exchange (TPE) is a well-established treatment modality for nephrology patients, using two conventional methods: membrane (mTPE) or centrifugal TPE (cTPE). Although the efficacy of both treatments has been described, there are few reports that compare these methodologies. Here we describe three nephrology patients who were treated with both mTPE and cTPE. The mTPE method, but not the cTPE method, was associated with persistent difficulty anticoagulating the extracorporeal circuit in all three patients. In mTPE procedures, the doses of heparin bolus and infusion rate were important determinants of whether the circuit clotted. With a heparin bolus at or below 2000 IU, clotting occurred in 67% of treatments, dropping to 25% with a bolus of >2000 IU. Likewise, a heparin infusion rate during the procedure was indicative of clotting. With a maintenance infusion of <2000 IU/h, most circuits clotted. No clotting was observed during cTPE procedures using acid citrate dextrose formula A solution as an anticoagulant of the extracorporeal circuit. Overall, difficulties maintaining the extracorporeal circuit in mTPE required the use of additional disposable sets, high doses of heparin and nursing time. In addition, mTPE procedures took longer to perform than cTPE.

Vascular access in therapeutic apheresis: update 2013

This review addresses the types of vascular access available for patients who need therapeutic apheresis (TA). As in hemodialysis, vascular access for TA is chosen based on type of procedure prescribed, the patient's vascular anatomy, the acuity, frequency and duration of treatment, and the underlying disease state. The types of access available include peripheral vein cannulation, central venous catheters: including nontunneled and tunneled catheters, arterio-venous grafts and arterio-venous fistulas. Peripheral veins and central venous catheters are most frequently utilized for the acute administration of TA, and may be used over a period of weeks to months. Arterio-venous grafts and fistulas are not commonly used in TA procedures, but are an option in patients with an anticipated long course of TA, usually for a period of several months or years. The types and frequency of complications associated with various types of vascular access, including: access dysfunction and infections are reviewed, and strategies for their prevention and management are offered.

Selective capture of anti-A antibodies from human blood using a novel integrated bead and hollow fiber module

Anti-A/B antibody removal from blood in the peritransplantation period facilitates ABO-incompatible transplantation and significantly increases the donor pool. We have been developing an anti-A/B immunoadsorption device (BSAF), compatible with whole blood perfusion. The BSAF is based on integrated microfiltration hollow fibers with antibody capturing beads uniformly distributed within the fiber interstitial space. In this study we fabricated BSAF prototypes, appropriately scaled down from a conceptual clinical scale device. We then, for the first time, measured the time course of anti-A capture from blood samples recirculating through the scaled down BSAF devices. We observed a significant reduction in IgM (96% ± 5%, n = 5, p < 0.001), and IgG (81% ± 18%, n = 5, p < 0.05) anti-A antibody titers within 2 h. We did not observe a significant change between the initial and final values of hematocrit, total plasma protein concentration, plasma free hemoglobin concentration, and anti-B antibody titer over five experiments. In conclusion we showed that the BSAF modules selectively removed anti-A antibodies from blood in a simple one step process, without requiring a separate plasmapheresis unit.

Diagnosis and treatment of pemphigus

Pemphigus is an autoimmune bullous disease, in which autoantibodies react with the cell–cell adhesion structures, desmosomes, causing blisters and erosions on the oral mucosa and skin. Pemphigus is divided into two major subtypes: pemphigus vulgaris and pemphigus foliaceus. Oral corticosteroids are the primary treatment modality for pemphigus, while other therapeutic options, such as steroid pulse therapy, immunosuppressants, intravenous immunoglobulins, plasmapheresis and anti-CD20 monoclonal antibody therapy, are occasionally employed. Immunosuppressants used to treat pemphigus include azathioprine, cyclophosphamide, cyclosporine, mycophenolate mofetil and mizoribine. In this review, we summarize the current concepts of immunotherapy for the treatment of pemphigus in the Japanese population.

Measuring the quality of therapeutic apheresis care in the pediatric intensive care unit

Our goal was to measure the quality of care provided in the Pediatric Intensive Care Unit (PICU) during Therapeutic Apheresis (TA). We described the care as a step by step process. We designed a flow chart to carefully document each step of the process. We then defined each step with a unique clinical indictor (CI) that represented the exact task we felt provided quality care. These CIs were studied and modified for 1 year. We measured our performance in this process by the number of times we accomplished the CI vs. the total number of CIs that were to be performed. The degree of compliance, with these clinical indicators, was analyzed and used as a metric for quality by calculating how close the process is running exactly as planned or "in control." The Apheresis Process was in control (compliance) for 47% of the indicators, as measured in the aggregate for the first observational year. We then applied the theory of Total Quality Management (TQM) through our Design, Measure, Analyze, Improve, and Control (DMAIC) model. We were able to improve the process and bring it into control by increasing the compliance to > 99.74%, in the aggregate, for the third and fourth quarter of the second year. We have implemented TQM to increase compliance, thus control, of a highly complex and multidisciplinary Pediatric Intensive Care therapy. We have shown a reproducible and scalable measure of quality for a complex clinical process in the PICU, without additional capital expenditure.

Specific antibody filter (SAF) binding capacity enhancement to remove anti-A antibodies

Removal of Anti-A/B antibodies prior to ABO-incompatible transplantation can prevent hyperacute organ rejection. We are developing a specific antibody filter (SAF) device to selectively remove ABO blood group antibodies from the whole blood by utilizing immunoaffinity adsorption. The device consists of ultrafiltration hollow fiber membranes with synthetic antigens specific to bind blood group antibodies immobilized on the inner lumenal walls of the fibers. The aim of this study was to evaluate the effect of antigen molecular weight and surface activation process to increase the antibody binding capacity of the fiber membrane surface. A new higher molecular weight antigen Atri-pNSA-1000 compared with Atri-pNPA-30 (A-trisaccharide (Atri) conjugated to activated polymers of Mol. wt. 1000 kDa and 30 kDa, respectively) was employed to improve accessibility of the antigen to bind antibodies. Also, a cyanogen bromide (CNBr) based surface activation method mediated by TEA in neutral pH medium was used to enhance the number of active sites for antigen binding compared to a strong basic medium of NaOH. Using a CNBr/TEA activation method and by immobilizing Atri-pNSA-1000 antigen, an antibody binding capacity (∼0.01 monoclonal anti-A IgM nmol/cm(2)) was achieved on the fiber surface. This binding capacity was sufficient to reduce monoclonal antibody titer from 1:128 to final titer below 1:4 with a surface area to volume ratio that is similar to commercial dialysis device (∼1.1 m(2) surface area for an average body blood volume of 5 L).

Treatment of Three Cats with Hyperviscosity Syndrome and Congestive Heart Failure Using Plasmapheresis

Three cats were evaluated at a veterinary teaching hospital for congestive heart failure (CHF) secondary to hyperviscosity syndrome from plasma cell neoplasia. All cats had severe hyperproteinemia due to hyperglobulinemia. Multiple myeloma or plasma cell neoplasia was diagnosed based on cytopathology and post mortem examination. The cats presented with signs of CHF including acute collapse, tachypnea, increased respiratory effort, and pulmonary crackles. All cats had heart murmurs and echocardiographic signs consistent with hypertrophic cardiomyopathy. An enlarged left atrium was found in all cats and two of three cats also had spontaneous echocardiographic contrast. Plasmapheresis (centrifugal plasma exchange) was performed on all three cats by the removal of whole blood and the infusion of a balanced electrolyte solution while the whole blood was centrifuged and separated. The RBCs were then washed before being readministered to the patient. Plasmapheresis alleviated the clinical signs of CHF (tachypnea) in all three cats. Plasmapheresis should be considered in cases of CHF secondary to hyperviscosity syndrome to rapidly alleviate clinical signs associated with heart failure while diagnosis of the underlying cause is made and appropriate therapy implemented.

Thrombotic microangiopathy in systemic lupus erythematosus: a cohort study in North Taiwan

OBJECTIVES

Thrombotic microangiopathy (TMA) co-existing with SLE is rarely reported. This study aimed to investigate the triggering factors, clinical features and outcomes of SLE patients with TMA in Northern Taiwan.

METHODS

Twenty-five TMA cases out of 2461 SLE patients admitted to Taipei Veterans General Hospital, between 2000 and 2010, were enrolled.

RESULTS

When TMA occurred, 16 (64.0%) patients had infection; 22 (88.0%) were in an active disease state with a SLEDAI score >10. Among the infection group, 13 (81.3%) had an increase in the SLEDAI score of ≥ 4. We found that older age (≥ 50 years), low platelets (≤ 20,000/nm(3)), presence of infection, acute renal failure (ARF) or four or more TMA features were independent risk factors for persistent haematological abnormalities (P < 0.05); older age (≥ 50 years) and a high reticulocyte index (>2%) were the risk factors for persistent renal function impairment (P < 0.05). The overall mortality rate was 52.0% (13 out of 25); older age (≥ 40 years), low complement value, presence of infection (P < 0.001), two or more infection sources, ARF and four or more TMA features were the statistically significant factors contributing to a higher mortality rate. Patients receiving plasma exchange seven times or more had a significantly higher rate of improvement in renal function and haematological abnormalities.

CONCLUSIONS

Our study showed that infection was one of the major triggers for the flare-up of SLE disease activity and occurrence of TMA in SLE. Infection is also a strong risk factor for outcome in SLE patients with TMA. Plasma exchange can be considered as an adjuvant treatment modality.

High molecular weight blood group A trisaccharide-polyacrylamide glycoconjugates as synthetic blood group A antigens for anti-A antibody removal devices

Specific immunoadsorption of blood group antibodies by synthetic antigens immobilized on support matrices in the peri-transplantation period provides a promising solution to hyperacute rejection risk following ABO-incompatible transplantation. In this study, we investigated binding interactions between anti-A antibodies and synthetic blood group A trisaccharide conjugated with polyacrylamide of different molecular weights (30 and 1000 kDa). The glycopolymers were equipped with biotin tags and deposited on streptavidin-coated sensor chips. The affinity and kinetics of anti-A antibodies binding to glycoconjugates were studied using surface plasmon resonance (SPR). The high molecular weight conjugate (Atri-PAA(1000)-biotin) enhanced antibody binding capacity by two to three fold compared with the low molecular weight conjugate (Atri-PAA(30)-biotin), whereas varying the carbohydrate content in Atri-PAA(1000)-biotin (20 mol % or 50 mol %) did not affect antibody binding capacity of the glycoconjugate. The obtained results suggest that immunoadsorption devices, especially hollow fiber-based antibody filters which are limited in available surface area for antigen immobilization, may greatly benefit from the new synthetic high molecular weight polyacrylamide glycoconjugates.

Monoclonal anti-A antibody removal by synthetic A antigen immobilized on specific antibody filters

Removal of blood group anti-A and anti-B antibodies can prevent hyperacute organ rejection in ABO-incompatible transplantation. We are developing an extracorporeal-specific antibody filter (SAF) as an immunoadsorption device for direct removal of ABO blood group antibodies from whole blood, without the need for plasma separation and plasma exchange. A hollow fiber-based small scale SAF (mini-SAF) device was fabricated and synthetic A antigen, Atrisaccharide (Atri) conjugated to activated polyacrylic acid, was immobilized on the fiber lumen surface. Monoclonal antibody anti-A IgM were specifically removed up to 70% of initial antibodies using mini-SAF device. The monoclonal anti-A capture experiments on mini-SAF indicated that antibody removal relative to the initial concentration is independent of inlet concentration in the beginning; however, as the surface starts saturating with bound antibodies, removal becomes dependent on inlet concentration. No significant effect of flow rate on removal rate was observed. The radial diffusion and axial convection-based mathematical model developed for unsteady state antibody removal was in good agreement with the experimental data and showed that the antibody removal rate can be maximized by increasing the antibody-binding capacity of the SAF.

Synthetic blood group antigens for anti-A removal device and their interaction with monoclonal anti-A IgM

Removal of blood group antibodies against the donor organ prior to ABO-incompatible transplantation can prevent episodes of hyperacute rejection. We are developing a specific antibody filter (SAF) device consisting of immobilized synthetic Atrisaccharide antigens conjugated to polyacrylamide (Atri-PAA) to selectively remove anti-A antibodies directly from whole blood. In this study, we evaluated eight anti-A IgM monoclonal antibodies (mAbs) using Enzyme-Linked Immunosorbent Assay (ELISA) to determine their specificity for binding to Atri-PAA. Five of the eight mAbs met our criteria for specificity by binding to Atri-PAA with at least five times greater affinity compared to the negative controls. These selected mAbs will be studied for their binding characteristics to Atri-PAA which will aid in the development of the SAF. The study of kinetics of antibody removal and quantification of antibody removal will be used in our mathematical model to maximize the antibody removal rate and binding capacity of the SAF.

Anticoagulation with low-molecular-weight heparin (dalteparin) in plasmapheresis therapy: initial experience

BACKGROUND

In contrast to other extracorporeal treatments no established regime exists for anticoagulation with low-molecular-weight heparin (LMWH) in plasmapheresis therapy. A study was conducted to investigate whether LMWH (dalteparin-Na) is suitable as an effective anticoagulant in plasmapheresis therapy.

STUDY DESIGN AND METHODS

Eleven patients with autoimmune neurological diseases and the necessity for a plasmapheresis therapy were enrolled. A capillary membrane filter was used. A total of 2000 mL of human plasma was isovolumetrically exchanged per plasmapheresis cycle. The anticoagulation was accomplished with a single bolus of LMWH (dalteparin) of 80 to 90 IU per kg of body weight. The system was visually monitored. Anti-factor (F)Xa activity, thrombin-antithrombin III complex (TAT), and prothrombin fragment 1+2 (F 1+2) were determined at regular intervals. Samples were taken from the collected plasma pool to determine the loss of LMWH during the plasmapheresis procedure.

RESULTS

All plasmapheresis cycles with LMWH were successful without complications. Approximately 40 percent of the initially administered LMWH bolus was lost by the large porous filter during the plasmapheresis. The anti-FXa values were determined to be 0.5 IU per mL during the entire plasmapheresis. TAT values were elevated (TAT median, 14.3 microg/L). F 1+2 values measured before the filter cartridge remained within the normal range for the entire plasmapheresis cycle (<1.2 nmol/L) and were increasingly elevated after the filter.

CONCLUSION

Our initial experiences with LMWH for anticoagulation in plasmapheresis indicate that a body weight adjusted dose of LMWH (dalteparin) is suitable for anticoagulation in plasmapheresis therapy. No complications were observed. The data are encouraging. Further investigations will show if and how the present anticoagulation regime could be further optimized.

The use of therapeutic plasmapheresis in the treatment of poisoned and snake bite victims: An academic emergency department's experiences

The objective of this study is to describe the clinical status, procedural interventions, and outcomes of critically ill patients with poisoning and snake bite injuries presenting to a tertiary-care emergency department for treatment with therapeutic plasmapheresis. Records of 20 patients who presented to our academic emergency department over a 2-year period and who underwent plasmapheresis for poisoning or snake bite were retrospectively reviewed. Plasmapheresis was performed using centrifugation technology via an intravenous antecubital venous or subclavian vein catheter access. Human albumin or fresh frozen plasma were used as replacement fluids. Data extracted from the patient record included demographic data, clinical status, and outcome measures. Sixteen patients underwent plasmapheresis because of toxicity from snake bite. Three patients were treated for drug poisoning (phenytoin, theophylline, bipyridene HCl) and one patient for mushroom poisoning. Haematologic parameters such as platelet count, PT, and INR resolved rapidly in victims of snake bite injuries after treatment with plasmapheresis. Loss of limbs did not occur in these cases. Seven patients required admission to the intensive care unit. One patient with mushroom poisoning died. Mean length of hospital stay was 14.3 days (range 3-28 days) for all cases. Plasmapheresis was a clinically effective and safe approach in the treatment of snake bite envenomation and other drug poisoning victims especially in the management of hematologic problems and in limb preservation/salvage strategies. In addition to established conventional therapies, emergency physicians should consider plasmapheresis among the therapeutic options in treatment strategies for selected toxicologic emergencies.

Plasmapheresis for the treatment of intrahepatic cholestasis of pregnancy refractory to medical treatment

Pruritus associated with intrahepatic cholestasis of pregnancy (ICP) is usually mild but some cases are refractory to medical treatment. We report a case of intractable ICP that was successfully treated with plasmapheresis. Plasmapheresis should be considered for ICP that is refractory to traditional therapies.

Challenges in the management of infantile factor H associated hemolytic uremic syndrome

We describe a 1-year old with four episodes of recurrent hemolytic uremic syndrome (HUS). Family history suggested an autosomal dominant mode of inheritance. Factor H concentrations in the blood were normal in the affected family members. Mutation screening in the human complement factor H gene ( HF-1) revealed a novel mutation in exon 23 (c.3546_3581dup36). The HF-1 gene encodes complement factor H and the mutation leads to the insertion of 12 additional amino acids after codon 1176 in factor H. The recurrent HUS responded to plasma infusions and renal function improved from a glomerular filtration rate of 21 to 50 ml/min per 1.73 m(2). The infusions of fresh-frozen plasma were necessary at once-weekly intervals at a dose of 40-45 ml/kg in order to maintain remission and resulted in significant hyperproteinemia. This was addressed by intermittent plasma exchange through an arterio-venous fistula. The prognosis and therapeutic dilemmas are discussed.