Therapeutic plasma exchange in a tertiary care center: 185 patients undergoing 912 treatments - a one-year retrospective analysis

Bioavailability and daily requirement of vitamin B12 in adult humans: an observational study of its colonic absorption and daily excretion as measured by [13C]-cyanocobalamin kinetics

BACKGROUND

Clinical and biochemical vitamin B12 (B12) deficiency is lower than anticipated in vegetarians. Extraileal absorption, such as from the colon, as well as reduced daily excretion, may be adaptive mechanisms to maintain B12 homeostasis with marginal intakes.

OBJECTIVE

To measure the absorption of B12 from the small and large intestine, and its daily rate of excretion from the body, using a [13C]-cyanocobalamin tracer.

METHODS

Oral B12 bioavailability was measured over 12 h after administration of [13C]-cyanocobalamin tracer (2.5 μg) in normal participants. The colonic B12 bioavailability was evaluated by direct instillation of [13C]-cyanocobalamin (5 μg) into the ascending colon. Bioavailability was calculated from 2-compartmental modeling of the tracer appearance in plasma. The excretion rate of B12 was measured from [13C]-cyanocobalamin elimination from the body over 4 wk after oral dosing (5 μg).

RESULTS

The oral B12 bioavailability (n = 11) was 63% ± 10% measured over 12 h. A late absorption peak, accounting for 12% of the absorption, was observed after an average lag time of 8.7 h from dosing. The colonic B12 bioavailability (n = 10) was 7% ± 5% over 4 h. The daily B12 excretion rate (n = 4) was 0.7 ± 0.2 μg/d. The minimum daily requirement of B12 in these participants was derived at 1 μg /d.

CONCLUSIONS

B12 is absorbed in the human colon. This observation confirms the potential contribution of the colon in daily B12 nutriture, and along with a possible lower requirement, could explain the absence of clinical deficiency in populations with marginal B12 intakes.

TRIAL REGISTRATION NUMBER

This study was registered in Clinical Trials Registry of India (CTRI) with the registration number CTRI/2018/04/012957, available from https://ctri.nic.in/Clinicaltrials/showallp.php?mid1=49319&EncHid=&userName=029108.

EXCHANGE-2: investigating the efficacy of add-on plasma exchange as an adjunctive strategy against septic shock-a study protocol for a randomized, prospective, multicenter, open-label, controlled, parallel-group trial

BACKGROUND

Sepsis is as a life-threatening organ dysfunction caused by a dysregulated host response to an infection. The mortality of sepsis and particular of septic shock is very high. Treatment mostly focuses on infection control but a specific intervention that targets the underlying pathological host response is lacking to the present time. The investigators hypothesize that early therapeutic plasma exchange (TPE) will dampen the maladaptive host response by removing injurious mediators thereby limiting organ dysfunction and improving survival in patients with septic shock. Although small prospective studies demonstrated rapid hemodynamic stabilization under TPE, no adequately powered randomized clinical trial has investigated hard outcomes.

METHODS

This is a randomized, prospective, multicenter, open-label, controlled, parallel-group interventional trial to test the adjunctive effect of TPE in patients with early septic shock. Patients with a refractory (defined as norepinephrine (NE) ≥ 0.4 μg/kg/min ≥ 30 min OR NE 0.3 μg/kg/min + vasopressin) and early (shock onset < 24 h) septic shock will be included. The intervention is a standard TPE with donor fresh frozen plasma (1.2 × individual plasma volume) performed within 6 h after randomization and will be compared to a standard of care (SOC) control arm. The primary endpoint is 28 days mortality for which the power analysis revealed a group size of 137 / arm (n = 274) to demonstrate a benefit of 15%. The key secondary objective will be to compare the extent of organ failure indicated by mean SOFA over the first 7 days as well as organ support-free days until day 28 following randomization. Besides numerous biological secondary, safety endpoints such as incidence of bleeding, allergic reactions, transfusion associated lung injury, severe thrombocytopenia, and other severe adverse events will be assessed during the first 7 days. For exploratory scientific analyses, biomaterial will be acquired longitudinally and multiple predefined scientific subprojects are planned. This study is an investigator-initiated trial supported by the German Research Foundation (DFG, DA 1209/7-1), in which 26 different centers in Germany, Switzerland, and Austria will participate over a duration of 33 months.

DISCUSSION

This trial has substantial clinical relevance as it evaluates a promising adjunctive treatment option in refractory septic shock patients suffering from an extraordinary high mortality. A positive trial result could change the current standard of care for this septic subgroup. The results of this study will be disseminated through presentations at international congresses, workshops, and peer-reviewed publications.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05726825 , Registered on 14 February 2023.

[Therapeutic plasmapheresis procedures: An alternative to the disruption of the supply of polyvalent immunoglobulin in autoimmune pathologies. Medico-economic study]

INTRODUCTION

The supply of human polyvalent immunoglobulin has been under severe pressure for several years. This has led to a prioritisation of indications and a record increase in the amount of reimbursement without solving the problem of demand. Treatment by therapeutic plasmapheresis appears to be an alternative to be considered for the treatment of certain dysimmune diseseases. To discuss this alternative, we are conducting a medico-economic study comparing the polyvalent immunoglobulin strategy versus different therapeutic plasmapheresis system in the treatment of a chronic dysimmune disease.

POPULATION AND METHOD

The medico-economic study was conducted using the example of a 75 kg patient with chronic polyradiculoneuritis dependent on chronic therapy with a comparison of sequential treatment with one session of therapeutic plasmapheresis versus a course of intravenous polyvalent immunoglobulin. The medico-economic study includes an evaluation from a public health care system perspective complemented by a hospital-based approach that justifies estimating the cost of different therapeutic plasmapheresis systems based on a bottom-up micro-costing approach.

RESULTS

From the point of view of the care system, for information, a 20 g bottle of polyvalent immunoglobulin has a similar cost to a therapeutic plasmapheresis session. In our example, the cost of a maintenance treatment repeated every 2 to 4 weeks in chronic polyradiculoneuritis in a 75 kg patient is 1284.13 euros for a therapeutic plasmapheresis session versus 7331.60 to 9426.84 euros for a 1.5 to 2 mg/kg polyvalent immunoglobulin treatment. Furthermore, from the point of view of the hospital system, the cost of the different TT techniques evaluated varies moderately with the cost depending mainly on the quantity of albumin infused or the medical device used.

CONCLUSION

In the chronic sequential treatment of chronic polyradiculoneuritis, the cost of therapeutic plasmapheresis could be lower than with polyvalent immunoglobulin from a healthcare system perspective. The cost to the health care facility between different therapeutic plasmapheresis techniques differs little. This study provides arguments suggesting that if therapeutic plasmapheresis can be implemented with a dedicated technical platform, it is a serious alternative to be considered without additional costs.

Clinical and biochemical endpoints and predictors of response to plasma exchange in septic shock: results from a randomized controlled trial

Background

Recently, a randomized controlled trial (RCT) demonstrated rapid but individually variable hemodynamic improvement with therapeutic plasma exchange (TPE) in patients with septic shock. Prediction of clinical efficacy in specific sepsis treatments is fundamental for individualized sepsis therapy.

Methods

In the original RCT, patients with septic shock of < 24 h duration and norepinephrine (NE) requirement ≥ 0.4 μg/kg/min received standard of care (SOC) or SOC + one single TPE. Here, we report all clinical and biological endpoints of this study. Multivariate mixed-effects modeling of NE reduction was performed to investigate characteristics that could be associated with clinical response to TPE.

Results

A continuous effect of TPE on the reduction in NE doses over the initial 24 h was observed (SOC group: estimated NE dose reduction of 0.005 µg/kg/min per hour; TPE group: 0.018 µg/kg/min per hour, p = 0.004). Similarly, under TPE, serum lactate levels, continuously decreased over the initial 24 h in the TPE group, whereas lactate levels increased under SOC (p = 0.001). A reduction in biomarkers and disease mediators (such as PCT (p = 0.037), vWF:Ag (p < 0.001), Angpt-2 (p = 0.009), sTie-2 (p = 0.005)) along with a repletion of exhausted protective factors (such as AT-III (p = 0.026), Protein C (p = 0.012), ADAMTS-13 (p = 0.008)) could be observed in the TPE but not in the SOC group. In a multivariate mixed effects model, increasing baseline lactate levels led to greater NE dose reduction effects with TPE as opposed to SOC (p = 0.004).

Conclusions

Adjunctive TPE is associated with the removal of injurious mediators and repletion of consumed protective factors altogether leading to preserved hemodynamic stabilization in refractory septic shock. We identified that baseline lactate concentration as a potential response predictor might guide future designing of large RCTs that will further evaluate TPE with regard to hard endpoints.

Trial registration Retrospectively registered 18th January 2020 at clinicaltrials.gov (Identifier: NCT04231994).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04003-2.

Extrakorporale Behandlungsstrategien der Sepsis

Hintergrund Die Mortalität der Sepsis bleibt auch im 21. Jahrhundert sehr hoch. Verschiedene adjuvante Strategien zur extrakorporalen Zytokinelimination wurden als zusätzliche therapeutische Maßnahmen bei Sepsis und septischem Schock untersucht.

Ziele Zusammenfassung einer Auswahl extrakorporaler Blutreinigungstechniken und der aktuellen Erkenntnisse in der klinischen Anwendung mit besonderem Schwerpunkt auf dem therapeutischen Plasmaaustausch.

Methoden Nicht systematische Literaturrecherche.

Ergebnisse Verschiedene extrakorporale Blutreinigungstechniken mit unterschiedlichen Evidenzniveaus hinsichtlich Zytokinelimination, Verbesserung der Hämodynamik und Verringerung der Mortalität werden derzeit klinisch eingesetzt. Die am ausführlichsten untersuchten Modalitäten umfassen die hochvolumige Hämofiltration/Dialyse mit und ohne High-Cut-off-Filter sowie Hämoadsorptionstechniken (einschließlich CytoSorb- und Polymyxin-B-Filter). Trotz teilweise ermutigender Beobachtungen bezüglich der Entfernung proinflammatorischer Zytokine und verbesserten Hämodynamik zeigten randomisierte Outcome-Studien bislang keinen positiven Einfluss auf das Überleben. Aufgrund der Verwendung von Spenderplasma als Substitutionsflüssigkeit stellt der therapeutische Plasmaaustausch das einzige Verfahren dar, das neben einer reinen Elimination zusätzlich verbrauchte protektive Faktoren ersetzen kann.

Schlussfolgerungen Die Anwendung extrakorporaler Blutreinigungsmethoden kann für Sepsispatienten außerhalb klinischer Studien bisher nicht empfohlen werden, da derzeit keine Beweise für ihre Wirksamkeit vorliegen. Zukünftige Untersuchungen sollten darauf abzielen, das Patientenkollektiv hinsichtlich des klinischen Schweregrads, des Zeitpunkts der Intervention und verschiedener inflammatorischer (Sub-)Phänotypen zu homogenisieren.

Comparison of centrifugal and membrane filtration modalities on therapeutic plasma exchange

BACKGROUND

Therapeutic plasma exchange (TPE) is a technique in which plasma is separated from the rest of the blood in an extracorporeal system and exchanged with appropriate fluids. Two main methods are used in the TPE process: membrane filtration (mTPE) and centrifuge-based (cTPE) TPE. We aimed to compare the efficacy of these methods and their effects on hemostatic parameters.

METHODS

A total of 88 TPE procedures performed on 51 patients were evaluated retrospectively. Hemostatic parameters, such as pre- and postoperative complete blood count, fibrinogen, and D-dimer levels were evaluated, as well as data recorded during the TPE application, such as preparation time, operation time, and plasma removal efficiency (PRE). The Fresenius multiFiltrate, software version 5.3 device was used for the mTPE procedure and the Spectra Optia device was used for cTPE.

RESULTS

While both modalities removed similar amounts of plasma, the total time to perform the cTPE treatment was significantly lower than the mTPE (107 [66-191] min vs 116.5 [80-181] min, respectively) (P = .026). At the PRE rate, the mTPE procedure was as effective as cTPE (86.8% ± 16.3 vs 85.15% ± 17.63 respectively, P = .64). The difference was not statistically significant, and this is the highest rate of PRE reported about the mTPE procedure in the literature.

CONCLUSIONS

To our knowledge, this is the first study directly comparing Fresenius and Spectra regarding mTPE and cTPE. While there were no statistically significant differences regarding PRE, treatment time of the mTPE was significantly longer than the cTPE treatment time.

Plasma exchange in the intensive care unit: a narrative review

In this narrative review, we discuss the relevant issues of therapeutic plasma exchange (TPE) in critically ill patients. For many conditions, the optimal indication, device type, frequency, duration, type of replacement fluid and criteria for stopping TPE are uncertain. TPE is a potentially lifesaving but also invasive procedure with risk of adverse events and complications and requires close monitoring by experienced teams. In the intensive care unit (ICU), the indications for TPE can be divided into (1) absolute, well-established, and evidence-based, for which TPE is recognized as first-line therapy, (2) relative, for which TPE is a recognized second-line treatment (alone or combined) and (3) rescue therapy, where TPE is used with a limited or theoretical evidence base. New indications are emerging and ongoing knowledge gaps, notably regarding the use of TPE during critical illness, support the establishment of a TPE registry dedicated to intensive care medicine.

Safety and tolerability of solvent/detergent‐treated plasma for pediatric patients requiring therapeutic plasma exchange: An open‐label, multicenter, postmarketing study

Background

This study investigated the real‐world safety and tolerability of solvent/detergent‐treated (S/D) plasma for pediatric patients requiring therapeutic plasma exchange (TPE).

Study design and methods

LAS‐213 was a multicenter, open‐label, interventional, phase 4 study. Patients (≥2 to ≤20 years) receiving TPE therapy were eligible. A total plasma volume of 40–60 ml/kg was recommended, with an infusion rate not exceeding 0.020–0.025 citrate/kg body weight/min (<1 ml/kg body weight/min). The primary endpoint was assessment of safety, monitoring the following: serious adverse events (SAEs), adverse drug reactions (ADRs), thrombotic events (TEs), thromboembolic events (TEEs), and specific laboratory tests.

Results

In total, 41 children (2 to <12 years [n = 15]; 12 to <17 years [n = 13]; ≥17 years [n = 13]) underwent 102 TPEs with a total of 135,137 ml of S/D plasma exchanged. Each patient group received between 1 and 6 TPEs (mean: 2.5 TPEs). Actual dose administered per TPE was 4–72 ml/kg (mean: 28.6 ml/kg), with a mean total volume of 1324.9 ml (range: 113–4000 ml). Overall safety was excellent for 96/102 (94.0%) TPEs. Six TPEs had a “moderate” safety profile for four patients experiencing eight ADRs. Of these, seven were mild in intensity and one (pyrexia) was moderate, all resolving by study end. Mild citrate toxicity (n = 2) was the most common ADR. One SAE was reported but was unrelated to the study drug. No TEs, TEEs, or changes in laboratory safety parameters were reported.

Conclusion

S/D plasma was well tolerated and demonstrated favorable safety, supporting the use of S/D plasma for TPE in pediatrics.

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.

Plasma exchange followed by convalescent plasma transfusion in COVID-19 patients

Background

Coronavirus disease 2019 (COVID-19) is an emerged pandemic disease with no specific treatment. One of the potential treatments in newly found infectious disease is plasma exchange (PE) with convalescent plasma transfusion (CPT). This case series aimed to evaluate the primary PE and CPT in five Iranian COVID-19 patients.

Methods

Five patients with confirmed COVID-19 who had acute respiratory distress syndrome and were supported by mechanical ventilation were treated with two consecutive PE containing fresh frozen plasma (FFP) of healthy donors and 0.9 % saline solution containing 5 % human albumin. Thereafter, CPT was performed just like PE, except that the FFP in this step was substituted with convalescent ABO-matched plasma. Clinical and laboratory factors were evaluated before and after treatments.

Results

Three to Four patients showed lower body temperature and improved oxygen saturation as well as reduced laboratory factors such as c-reactive protein, lactate dehydrogenase, creatine phosphokinase (total and myocardial isoform), aspartate aminotransferase, blood urea nitrogen, bilirubin (total and direct), D-dimer, interleukin-6, and CD4+/CD8 + T cells ratio initially after PE and continued to improve so that they were discharged. One patient due to secondary hemophagocytic lymphohistiocytosis and extensive lung fungal infection was expired.

Discussion

Overall, the PE followed by CPT was beneficial in reducing acute inflammation led to a considerable improvement in patients’ clinical features. It seems that PE along with CPT could provide clearance of pro-inflammatory mediators as well as the positive effects of CPT. Controlled studies are required to confirm the effect of PE/CPT compared with other therapeutic approaches.

[Extracorporeal Strategies in Sepsis Treatment: Role of Therapeutic Plasma Exchange]

BACKGROUND

 Mortality in sepsis remains high. Various techniques for extracorporeal cytokine removal have been investigated as additional therapeutic measures in sepsis and septic shock.

OBJECTIVES

 To summarize a selection of extracorporeal blood purification techniques, with a special focus on therapeutic plasma exchange, and their current evidence in clinical use.

METHODS

 Non-systematic literature review.

RESULTS

 Various extracorporeal blood purification techniques with different levels of evidence regarding cytokine removal, vasopressor sparing effects and reduction of mortality are currently in clinical use. Most extensively studied modalities include high-volume hemofiltration/dialysis with and without high cut-off filters a well as hemoadsorption techniques (including CytoSorb, and polymyxin-B filters). Despite partly encouraging observations regarding removal of inflammatory cytokines and hemodynamic stabilization, results from randomized studies did not show an effect on survival. Due to use of donor plasma as substitution fluid, therapeutic plasma exchange represents the only modality able to additionally replace protective and consumed factors.

CONCLUSIONS

 The use of extracorporeal blood purification methods cannot be recommended for sepsis patients outside of clinical trials given the current lack of evidence of their efficacy. Future investigations should aim to homogenize the studied patient collective in respect to clinical sepsis severity, time point of intervention and different inflammatory (sub-)phenotypes.

Therapeutic Plasma Exchange Using Membrane Plasma Separation

Therapeutic plasma exchange is a blood purification technique designed for the removal of large molecular weight toxins such as pathogenic antibodies and lipoproteins. Plasma exchange can be performed either by membrane separation or centrifugation. Centrifugal plasma exchange is more common in the United States, while membrane separation is more popular in Germany and Japan. The membrane separation technique is similar to the ultrafiltration procedures performed with a standard dialysis machine but in which the membrane's pores are large enough to allow removal of all circulating molecules while retaining the cellular components. The current availability of plasma separation membranes compatible with CRRT systems has dramatically increased the potential for almost all nephrologists to perform these treatments. This review describes the membrane separation techniques available in the United States, the practical aspects of ordering and operating a membrane separation plasma exchange procedure, and its possible complications.

Therapeutic plasma exchange (TPE) for semi-critical neurology presentations in a non-acute neurology set-up: clinical practice and challenges

Introduction

Therapeutic plasma exchange (TPE) for semi-critical neurological manifestations can be managed in non-acute setting instead of critical care unit. In 2014, we established a non-acute neurology TPE unit for semi-critical haemodynamically stable patients. In this study, we aimed to evaluate the technical and safety parameters from the first 3 years of service.

Materials and methods

We analysed prospectively collected TPE data for patients treated with centrifugation TPE at our non-acute neurology TPE unit in Kuala Lumpur Hospital between May 2015 and June 2018.

Results

A total of 245 TPE procedures were performed in 55 patients for nine neurological indications, predominantly the central nervous system (79%). Twenty four per cent (n=13) had category I and 73% (n=40) had category II indication (American Society for Apheresis (ASFA) 2019). Others (4%) were not in ASFA indications. Neuromyelitis optica spectrum disorders accounted for half (51%) of the total patients. Twenty-three (41.8%) patients experienced adverse events, with hypotensive episodes being the the most common (n=12/55, 21.8%). Five (9.1%) patients had catheter-related blood stream infection, correlating with higher exchange plasma volume (p=0.023). Symptomatic hypocalcaemia was less common (n=5/55, 9.1%) and allergic reaction to human albumin was rare (n=1/55, 1.8%). Four technical errors detected. Three involved centrifugation sets manufacturing defects and one involved error in centrifugation set installation. Seven (2.9%) procedures were terminated: 5 for adverse effects and 2 for technical errors.

Conclusion

Performing TPE among semi-critical patients with neurology manifestations in basic non-acute set-up proved safe, with predictable complications. This set-up reduced the reliance on critical care services for TPE procedures.

Therapeutic plasma exchange in neurological disorders: Experience from a tertiary neuroscience centre

Therapeutic plasma exchange (TPE) involves the extracorporeal separation of plasma from the cellular components of blood with replacement fluid, such as human albumin or fresh frozen plasma. A number of studies across the world revealed that more than one third of TPE procedures were performed for neurological disorders. Myasthenia gravis (MG), Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP) were the most frequently cited indications for TPE, followed by multiple sclerosis (MS). However, treatments of these conditions have evolved over the years and it is likely that this has impacted on clinical practice. Here we present our experience of using TPE to treat neurological disorders. We reviewed the medical records of all 63 patients who received 349 procedures over 70 therapeutic cycles between 2012 and 2015 in a tertiary neurology centre. In total only 2 patients with GBS and MG were treated with TPE. The commonest indication was voltage gated potassium channel (VGKC) complex antibody associated disorders followed by CIDP and MS. There were 11 patients with limbic encephalitis. Nine of them had antibodies against VGKC complex and two had N-methyl-D-aspartate (NMDA) receptor antibodies. Sixty four percent of patients with limbic encephalitis and overall 78% of patients responded to TPE. The complication rate associated with this procedure was 8.6 per 100 therapeutic cycle. There was no treatment related mortality. We observed a change in indications of TPE compared to historical studies. It was less frequently used to treated GBS and MG. It was found to be safe and effective.

[What are the indications for rescue procedures? : Systemic rheumatic diseases in the intensive care unit]

Schwere, organ- oder lebensbedrohliche Manifestationen entzündlicher rheumatischer Erkrankungen, wie z. B. eine diffuse alveoläre Hämorrhagie im Rahmen einer Kleingefäßvaskulitis, sprechen nicht immer ausreichend oder mit zeitlicher Verzögerung auf eine immunsuppressive Therapie an. Bei einem drohenden oder bereits eingetretenen Organversagen besteht dann nicht selten die Notwendigkeit, die immunsuppressive Therapie auf der Intensivstation um rasch wirksame Rescue-Therapieverfahren zu ergänzen. Aufgrund der Seltenheit vieler rheumatischer Erkrankungen ist die Evidenz zum Einsatz von Rescue-Therapieverfahren wie der Plasmapherese, der extrakorporalen Membranoxygenierung (ECMO) oder der Gabe von intravenösen Immunglobulinen (IVIG) für viele Indikationen eher gering. Der Einsatz der Plasmapherese wird bei einer akuten Anti-GBM(glomeruläre Basalmembran)-Erkrankung (Goodpasture Syndrom) oder einem katastrophalen Antiphospholipidantikörpersyndrom (CAPS) als sinnvoll angesehen. Eine ECMO-Therapie kann bei persistierender respiratorischer Insuffizienz trotz mechanischer Beatmung als Folge einer diffusen alveolären Hämorrhagie oder eines Acute-Respiratory-Distress-Syndroms (ARDS) anderer Ursache erwogen werden. Eine Gabe von IVIG ist bei einer akuten kardialen Beteiligung im Rahmen einer Kawasaki-Erkrankung indiziert und kann beim CAPS sowie bei therapierefraktären Myositiden erwogen werden.

Chronic Renal Failure as a Possible Risk Factor for Allergic Reaction in Therapeutic Plasma Exchange Using Fresh Frozen Plasma

The incidence of allergic reactions in patients with chronic renal failure during plasma exchange using fresh frozen plasma is not well known. We retrospectively reviewed 62 patients who underwent plasma exchange between January 2013 and May 2018. The most common indication for plasma exchange was desensitization/preconditioning for kidney transplant (61.3%, 38/62). The incidence of allergic reactions was significantly higher in patients with chronic renal failure than patients without (57.1% vs. 25.0%, P = 0.029). Also, the incidence of allergic reactions tended to be higher in peritoneal dialysis patients (75%, 3/4) than in hemodialysis (58.8%, 10/17) and preemptive kidney transplant (58%, 11/19). These results suggested the relationship of chronic renal failure and the incidence of allergic reactions in patients undergoing therapeutic plasma exchange using fresh frozen plasma.

A two-year analysis of therapeutic apheresis practices in a tertiary center: are we chasing the new indications?

BACKGROUND

Therapeutic apheresis (TA) as primary or adjunctive therapy proved itself in a broad spectrum of diseases. This study aims to present TA practices in a tertiary center with an emphasis on the rate of the utility of TA on the new American Society for Apheresis (ASFA) indications.

METHODS

We conducted a retrospective analysis of data regarding TA applications through our electronic medical database from June 2016 to July 2018. The data included demographics, clinical indications, and procedural characteristics. We also searched for the rate of the utility of TA procedures on new ASFA indications by entering both the diagnostic and TA modality codes for these indications on the electronic database during the study interval.

RESULTS

A total of 720 TA procedures were performed on 96 patients (54 males, 42 females, with a mean age of 48.15 ± 26.71 years). The procedures were 68.8 % therapeutic plasma exchange (TPE), 16.4 % leukocytapheresis, 11.5 % immunoadsorption (IA), 3.1 % double filtration plasmapheresis (DFPP), and 0.13 % erythrocyte exchange. The categorical indications included 60.41 % category I and category II, 28.12 % category III, and 1.04 % category IV. The most common indication was thrombotic thrombocytopenic purpura (TTP) (26.04 %). The procedure failure rate was 2.08 %. Patient-related adverse events were reported in 7.5 % of procedures. The case mortality rate was 16.66 %. TA utility rate was 0.98 % for the new indications in the ASFA 2016 guideline.

CONCLUSION

Therapeutic apheresis is a progressively developing, safe, and effective treatment modality with add-on indications.  Physicians should keep track of new developments on this modality to implement the appropriate indications into clinical practice. HIPPOKRATIA 2018, 22(4): 167-172.