Cascade filtration for TTP: an effective alternative to plasma exchange with cryodepleted plasma

Cascade Filtration (CF) with the Haemonetics MCS+: A New Technical Adaptation

CF was introduced in clinical medicine in 1980. Up to now, exclusively two-vein procedures have been carried out with some limitations to expansion of this technique. In this report we describe the very first application of single-needle CF carried out with Haemonetics MCS + apparatus. Twenty procedures were completed without any untoward effect in patients suffering from TTP, post-hepatitic cryoblobulinemia, familial hypercholesterolemia and acute Guillan-Barrè Syndrome. From 1 to 4 sessions were carried out per patient with the expected laboratory and clinical results. The only limit is the procedure time that averages 231 +/- 48 min., approximately 40% longer than two needle procedures.

Treatment of atypical hemolytic uremic syndrome and thrombotic microangiopathies: a focus on eculizumab

Uncontrolled complement activation is central to the occurrence of atypical hemolytic uremic syndrome (aHUS) and can result in thrombotic microangiopathies (TMAs). These terms encompass a group of heterogenic inherited or acquired diseases that recent research suggests may be triggered by the complement cascade. Pathogenetic triggers of complement activation include immunologic disorders, genetics, infections, systemic diseases, pregnancy, drug administration, metabolic diseases, transplantation, or triggers of mixed cause. Hallmarks of aHUS and other TMAs include increased vascular endothelium thromboresistance, leukocyte adhesion to damaged endothelium, complement consumption, coagulation abnormalities, and vascular shear stress, whereas common end points of these mechanisms include hemolytic anemia, thrombocytopenia with microvascular infarction, and predisposition for decreased kidney function and other organ involvement. The central role of the complement cascade as a disease trigger suggests a possible therapeutic target. Eculizumab, a first-in-class humanized monoclonal anti-C5 antibody that has been successful in the treatment of paroxysmal nocturnal hemoglobinuria, a disorder of complement-induced hemolytic anemia, received approval for the treatment of aHUS in the United States and Europe in late 2011. We review the treatment of aHUS and other TMAs, focusing on the role of eculizumab, including its pharmacology, mechanism of action, and approved dosing recommendations and health economic considerations. Finally, the potential for future indications for eculizumab use in other complement-driven diseases is discussed.

[Ultrasound-guided image fusion with computed tomography and magnetic resonance imaging. Clinical utility for imaging and interventional diagnostics of hepatic lesions]

Abdominal ultrasound is often the first-line imaging modality for assessing focal liver lesions. Due to various new ultrasound techniques, such as image fusion, global positioning system (GPS) tracking and needle tracking guided biopsy, abdominal ultrasound now has great potential regarding detection, characterization and treatment of focal liver lesions. Furthermore, these new techniques will help to improve the clinical management of patients before and during interventional procedures. This article presents the principle and clinical impact of recently developed techniques in the field of ultrasound, e.g. image fusion, GPS tracking and needle tracking guided biopsy and discusses the results based on a feasibility study on 20 patients with focal hepatic lesions.

Local experience with thrombotic thrombocytopenic purpura from the western part of Turkey

Thrombotic thrombocytopenic purpura (TTP) is a fatal disorder if left untreated. Therapeutic plasma exchange (PE) has resulted in excellent remission and survival rates in these patients but there is a need for alternative immuno-modulatory treatments in unresponsive patients. We present a descriptive, retrospective study of 25 (14 female, 11 male) adult patients admitted to our hematology unit with TTP. The patients' median age was 32 years. The patients were treated with immediate PE and a standard dose of corticosteroid therapy. Twenty percent of the patients obtained a complete response after the addition of Intravenous immuno-globulin (IVIg). Improvement of clinical status, platelet counts and serum LDH levels were seen after a median 13, 14 and 3.5 PE sessions, respectively. The mortality rate was 12%. One patient has a chronic relapsing form of TTP and two patients have relapsed. All the other patients are still in complete remission after a median of 7 years of follow-up. Although PE therapy is life-saving and the application of early corticosteroid treatment could obtain early and durable responses, addition of other immuno-modulatory treatments are needed in unresponsive patients. The use of IVIg could result in a dramatic response.

Nine Years of Cascade Filtration for Thrombotic Thrombocytopenic Purpura

Thrombotic thrombocytopenic purpura (TTP) continues to attract physicians' attention because of its unpredictable course and underlying pathogenetic mechanisms. It is also attractive because of its optimal response to therapeutic plasma exchange (PE) even in the most severe cases. The usual approach to its treatment is conventional PE with plasma substitution and only recently fresh frozen plasma (FFP) has been substituted by cryodepleted or virally inactivated plasma with clinical results that are, if not better, at least comparable with the ones attained when FFP is employed. Nonetheless, no consensus exists regarding the optimal PE fluid and this is not of marginal interest as even after PE treatment mortality is still from 15 to 20%. On the contrary, some consensus exists on the pathogenetic relevance of the exceedingly large Von Willebrand (vWF) multimers whose presence parallels the clinical course and appears to be determined by the abnormalities in the production or function and survival of vWF-cleaving proteases which is auto-antibody mediated. In both cases plasmapheresis without plasma infusion is relatively ineffective, perhaps because it does not increase protease activity. Paradoxically, cascade filtration (CF) can produce the same favorable results without replacing any protease activity. As with CF, the replacement is the autologous plasma with approximately 20% levels of vWF, fibrinogen, fibronectin, IgM and circulating immune complexes and 75% of albumin, IgGs, AT III and proteins whose molecular weight exceeds 250-300000 Da. Our experience with CF for TTP began in 1994. Since then, 16 patients have undergone CF combined with decreasing amounts of FFP supplementation and since 1998 without any allogeneic FFP supplementation in 9 cases. Twenty-four patients (96%) treated with no or minimal amounts of FFP survived but four (16%) experienced from one to four recurrences associated with cutaneous, paradental, cholecystic and vaginal infections. Only one patient died (5%) after the second CF procedure. There were no untoward effects related to the procedure itself and up to 18 procedures in one patient were carried out over 16 months, 10 with the patient in her sixth month of pregnancy and four in the post partum period in preparation for a splenectomy. Remission was achieved after an average number of treatments (10.7 +/- 6.8); a result that compares favorably with those of our historical control group of 47 cases (14 +/- 13). The patient's exposure to allogenic plasma which was 10.8 +/- 4.6 plasma U/session was reduced to 0 in 10 patients, to 1.4 +/- 1.2 and 4.4 +/- 2.3 plasma U/session, respectively, for seven and nine patients receiving PE + CF and CF with same plasma supplementation as described in our previous article. Based on our experience, we believe CF is presently the optimal treatment for patients with classic, sporadic TTP.