American Society for Apheresis guidelines on the use of apheresis in clinical practice: practical, concise, evidence-based recommendations for the apheresis practitioner

Short-term outcome of plasma adsorption therapy in amyotrophic lateral sclerosis

Background

To observe the short-term outcome of plasma adsorption PA therapy in amyotrophic lateral sclerosis (ALS).

Methods

28 cases of als patients were recruited in this study, of which 20 were male and 8 were female with a mean age of 53.21±9.07 years and the average course of 33±23.35 months. The clinical manifestations were limb weakness (N=27), muscular atrophy (N=27), muscular tremor (N=5), dysphagia (N=12) and dysarthria (N=12). The clinical data of the patients recruited were graded by Amyotrophic Lateral Sclerosis Functional Rating Scale Revised (ALSFRSR) : <10 (N=1), 11-20 (N=4), 21-30 (N=6), 31-40 (N=12), >40 (N=5). All patients received PA therapy once a week for three successive times after examining the conditions of blood coagulation and virus infection. PA therapy was supplemented with neurotrophic therapy meanwhile. All patients' clinical manifestations and scores of ALSFRSR before treatment and one week after treatment were evaluated and compared. The levels of serum superoxide dismutase (SOD), interleukin-10 (IL-10), serum creatine kinase (CK) and lactate dehydrogenase (LDH) before and after treatment were compared.

Results

After PA therapy, 14 patients have improved obviously in muscle strength, 4 patients in hypermyotonia partially, 3 patients in muscular tremor, 5 patients in dysarthria, 3 patients in salivation to some extent and 2 patients in swallowing function. The score of ALSFRSR after PA treatment (31.89±10.36) was remarkably higher than that before PA treatment (30.68±10.52) (P<0.01). The levels of SOD (155.10±21.87 IU/L) and IL-10 (138.06±185.88 pg/mL) after PA treatment were significantly higher than the levels before PA treatment (143.08.3±19.16 IU/L and 46.34±75.31 pg/mL, respectively) (P<0.05). The levels of CK (168.86±113.50 IU/L) and LDH (152.07±32.65 IU/L) after PA treatment were significantly lower than the levels before PA treatment (356.68±250.30 IU/L and 181.36±33.74 IU/L respectively) (P<0.01). At the end of follow-up period (November, 2019), five patients died of respiratory failure 16-21 months after PA treatment and two patents died of respiratory infection 15-20 months after PA treatment. 7 patients were still alive. The score of ALSFRS-R of these patients who survived at the end of follow-up (13.00±13.37) were significantly lower than before PA treatment (36.71±8.56) (P<0.05) and after PA treatment (38.14±8.82) (P<0.05).

Conclusions

Plasma adsorption (PA) therapy has shortterm therapeutic effects on als. The effects might be attributed to the anti-oxygen free radical effect by increasing SOD level and the anti-inflammation effect by increasing IL-10 level. As the efficacy of PA therapy was obtained in a small sample size and short follow-up period, the longterm observation of PA efficacy in treating als should be further investigated.

The Clinical Efficacy of Double Plasma Molecular Absorption System Combined with Plasma Exchange in the Treatment of Acute-on-Chronic Liver Failure: A Systematic Review and Meta-Analysis

Objective

This study aims to investigate the clinical efficacy of plasma exchange in treating acute-on-chronic liver failure (ACLF) through meta-analysis.

Method

PubMed, Web of Science, Embase, China National Knowledge Infrastructure (CNKI), and Wanfang databases were searched using a computer for all relevant Chinese and English literature from 2000 to 2021 in each database. At the same time, a large number of related papers and materials were manually consulted. Randomized controlled trials of plasma exchange (PE, control group) and combined double plasma molecular absorption system (DPMAS + PE, observation group) for the treatment of ACLF were collected. Meta-analysis was performed with Stata16.0 software.

Result

A total of 474 articles were retrieved, and 11 papers were finally included for research after screening. Meta-analysis results showed that the effective rate of treatment in the experimental group was significantly higher than that in the control group. At the same time, the observation group's prothrombin activity (PTA) level was better than that of the control group after treatment. After treatment, there was no significant difference in prothrombin time (PT) and international normalized ratio (INR) between the two groups. In addition, after treatment, the alanine aminotransferase (ALT) level of the observation group was significantly lower than that of the control group. However, TBIL levels and albumin (ALB) levels did not change significantly between the two groups. Regarding blood routine indexes, there were no significant changes in creatinine (Cr) levels and platelet counts (PLT) in the two groups after treatment, but hemoglobin (HGB) levels in the observation group were significantly lower than those in the control group.

Conclusion

DPMAS combined with plasma exchange therapy can improve liver function, coagulation function, and blood routine level of ACLF patients and increase the effective rate of treatment. It is an effective treatment for acute-on-chronic liver failure.

The relationship between triglyceride level and the severity of acute hypertriglyceridemic pancreatitis in Chinese patients

BACKGROUND/AIMS

The aim of this study was to investigate the relationship between the triglyceride (TG) level and the severity of acute hypertriglyceridemic pancreatitis (AHTGP) in Chinese patients.

MATERIALS AND METHODS

On the basis of clinical data on AHTGP, patients from the period 2015-2018 were enrolled retrospectively and grouped according to the 2012 revised Atlanta classification. Kruskal-Wallis test was performed to evaluate differences among groups. Receiver operating characteristic (ROC) curves were generated to assess the ability of parameters to distinguish mild acute pancreatitis (MAP)/moderately severe acute pancreatitis (MSAP) from severe acute pancreatitis (SAP).

RESULTS

A total of 104 patients with AHTGP were enrolled and divided into three groups: 61 patients with MAP, 29 patients with MSAP, and 14 patients with SAP. The median values for the MAP, MSAP, and SAP groups were as follows: TG level 48 h after admission, 3.4, 4.5, and 14.2 mmol/L, respectively (p<0.001); ratio of TG level 48 h after admission to that 0 h after admission (48:0-h ratio), 19.4, 32.1, and 65.9, respectively (p<0.001). ROC curves showed that the areas under the curves for the TG level 48 h after admission and the TG 48:0-h ratio for predicting SAP were 0.965 and 0.917, respectively (p<0.001), and the optimal cut-off values were 7.8 mmol/L and 37.7, respectively.

CONCLUSION

The TG level 48 h after admission and the TG 48:0-h ratio may predict the severity of AHTGP, and a high TG level 48 h after admission may be correlated with the progression of SAP.

Frequency of Alterations in Apheresis-Related Abstracts Prior to Publications as Peer-Reviewed Articles

High-quality evidence supporting clinical practice is lacking in apheresis. A potential source of evidence is provided by abstracts submitted to the Annual Meetings of the American Association of Blood Banks (AABB) and the American Society for Apheresis (ASFA). However, there is potential for study conclusions to be altered significantly following abstract presentations prior to publications in peer-reviewed journals. Therefore, we evaluated the discordance rate between apheresis-related meeting abstracts and their corresponding published articles. Abstracts accepted to either AABB or ASFA Annual Meetings from 2005 to 2012 and corresponding PubMed-indexed peer-reviewed articles' abstracts published prior to 9/2014 were reviewed for altered methods, results, and conclusions. When present, changes were evaluated for clinical significance. During the 8-year period, 198 out of 1152 abstracts were published as peer-reviewed articles. Of these, 36 (18.2%) presented discordant results, six of which (16.7%) were potentially clinically significant. An alteration in results (58.3%) was the leading reason for discordance. The discordance rate for ASFA abstracts was significantly higher (HR = 4.69, P = 0.0028) than the AABB ones. However, clinically significant alterations occurred more frequently among AABB abstracts (P = 0.025). Approximately 18% of meeting abstracts demonstrated alterations prior to publication in peer-reviewed journals. Given that approximately one in six changes represented clinically significant alterations, potentially affecting clinical practice, we recommend caution when modifying one's clinical practice based on abstract presentations at Annual Meetings. Future studies involving abstracts from both the International Society for Apheresis and the World Apheresis Association should also be performed.

EFFICACY OF INSULIN, HEPARIN AND FENOFIBRATE COMBINATION TREATMENT IN SEVERE HYPERTRIGLYCERIDEMIA: DOUBLE CENTER EXPERIENCE

Context

Severe hypertriglyceridemia (SH), which calls for a triglyceride (TG) level above 1000 mg/dL, remains an important health issue. While some data exist to offer combination of heparin, insulin and fenofibrate as a reasonable treatment option, safety and benefits of this therapy have not been accurately weighted, largely due to the limited sample size of the relevant studies.

Aim

Assess the efficacy and safety of the heparin, insulin and fenofibrate combination in the treatment of patients with SH.

Patients - Methods

Patients aged ≥18 years with TG level above 1000 mg/dL and adequate organ function were included. Triglyceride levels were measured immediately before the treatment and on the 3^rd and 6^th days of the treatment. Treatment dosage, duration, response and side effects were assessed. Patients with hypertriglyceridemia presenting with acute pancreatitis were treated additionally with lipid apheresis.

Results

A total of 42 patients were included. Of these, 85.8% came to medical attention with some kind of secondary hypertriglyceridemia causes. The baseline median TG value of the cases was 2141.0 mg/ dL (1026-12250). There were 6 patients (14.3%) with acute pancreatitis at presentation. In patients without pancreatitis, with administration of insulin infusion, unfractionated heparin infusion and fenofibrate capsule, median TG values decreased to 921 mg/ dL (190-6400) on the 3^rd day and to 437 mg/ dL (112-1950) on the 6^th day of the treatment (p<0.0001, Friedman test). Potential toxicities related to insulin, heparin and fenofibrate combination treatment including hypoglycemia, hemorrhage, rise in creatine kinase levels, hepato - and nephrotoxicity were not observed.

Conclusion

In this trial involving patients with SH, our data suggest that insulin, heparin and fenofibrate combination therapy was safe and effective.

Role of therapeutic plasma exchange in the treatment of severe hypertriglyceridemia: an experience

Hypertriglyceridemia of obesity, the metabolic syndrome, and type II diabetes mellitus are highly prevalent in Saudi Arabia. Severe hypertriglyceridemia is a rare but well known cause of acute pancreatitis. In treatment pancreatic rest, lifestyle changes, and lipid-lowering medications are essential, but the response is slow. Recently the role of therapeutic plasma exchange (TPE) has been stressed for fast and effective management in addition to insulin and heparin infusion. TPE for hypertriglyceridemic pancreatitis resulted in drastic improvements in clinical and laboratory findings and patient outcomes as suggested in our cases. However, this procedure is limited due to its high cost and availability only in specialized hospitals.

[Therapeutic plasma exchange for the treatment of hypertriglyceridemia-induced pancreatitis : A case report]

A rare but serious form of pancreatitis is caused by severe hypertriglyceridemia. It accounts for up to 10 % of all acute pancreatitis episodes. Despite a pathophysiology that differs distinctly from other forms of pancreatitis, there are no accepted guidelines for the treatment of hypertriglyceridemia-induced pancreatitis. We report a morbidly obese (BMI 45 kg/m²) 36-year-old Caucasian woman with a history of schizophrenic psychosis who was transferred to our tertiary care hospital for further diagnosis and treatment of increasing abdominal pain and hypertryglyceridemia of 2757 mg/dl. Due to rapid clinical deterioration, requiring invasive mechanical ventilation we performed therapeutic plasma exchange (TPE). About 1.5 times of the patient's calculated plasma volume was exchanged using fresh frozen plasma as substitution fluid. After a single TPE the triglyceride levels decreased by 86 % to 387 mg/dl. Concomitantly C‑reactive protein decreased from 303 to 179 mg/dl. Despite the paucity of data, TPE may be a beneficial means to lower triglycerides in patients with hypertriglyceridemia-induced pancreatitis, due to the rapid removal of the causative agent leading to pancreatic injury.

Apheresis research-more abstracts should be published as full manuscripts to provide more evidence for clinical practice guidelines

High-quality evidence to support clinical practice is lacking in apheresis medicine compared to other therapeutic modalities. A potential source of evidence comes from the abstracts submitted to the Annual Meetings of the American Society for Apheresis (ASFA). Therefore, the goal of this study is to determine the proportion of abstracts from the 2005 to 2012 ASFA Annual Meetings that subsequently became PubMed-indexed publications. Furthermore, we sought to determine the factor(s) that were associated with the likelihood of abstracts to be published as full manuscripts. During the 8-year study period, 684 abstracts were available for analysis (median: 82/year, range: 64-118). Most abstracts (74%) were from US institutions, and 67% of first authors were affiliated with academic centers. There were more abstracts (64%) on therapeutic versus donor apheresis (20%) and cellular therapy (16%). Overall, 16% of the abstracts have been published in PubMed-indexed journals, with a median time of 17 months from the ASFA Annual Meeting (range: 1-96 months). Abstracts whose first authors were affiliated with academic institutions were 3.14 times more likely to have been published than abstracts with ones affiliated with an apheresis organization and/or a community hospital. However, neither the first author's location nor the type of apheresis procedure significantly affected the publication rate after adjusting for other covariates. In conclusion, the rate of publication is low and authors should be encouraged to follow their presentations at the meeting with peer-reviewed manuscripts. This change is essential to provide more published evidence for future apheresis practice guidelines. J. Clin. Apheresis 31:353-358, 2016. © 2015 Wiley Periodicals, Inc.

The role of apheresis in hypertriglyceridemia-induced acute pancreatitis: A systematic review

BACKGROUND

Mostly published as case reports or series, the role of apheresis in hypertriglyceridemia (HTG)-related acute pancreatitis (AP) remains unclear. We performed a systematic review of available literature on this topic with specific focus on disease severity.

METHODS

A search of electronic databases (PubMed, EMBASE, Cochrane) and gray literature yielded 5020 articles of which 74 met criteria for inclusion (301 unique patients). Relevant data were abstracted from full manuscripts and analyzed.

RESULTS

Most patients were young (mean age 37.9 ± 10.4 years) and male (71.5%). About two-thirds (69.7%) received apheresis within 48 h and most required only 1 or 2 sessions (84.4%). Apheresis resulted in an average reduction of serum TG by 85.4% (p < 0.001). There was high variability in reporting the presence of and criteria to define severe AP (reported 221/301, 73.4%; present 85/221, 38.5%) or organ failure (reported 104/301, 34.6%; present 52/104, 50.0%). Improvement was reported in the majority of patients (reported 144/301, 47.8%, present 136/144, 94.4%) mainly by clinical symptoms or laboratory tests. Overall mortality was 7.1% (21/294) which increased to 11.8% (10/85) with severe AP and 19.2% (10/52) with organ failure.

CONCLUSIONS

Apheresis effectively reduces serum TG levels. However, due to uncontrolled data, reporting bias and lack of a comparison group, definitive conclusions on the efficacy of apheresis in reducing AP severity cannot be made. We propose which patients may be best suitable for apheresis, type of studies needed and outcome measures to be studied in order to provide empiric data on the role of apheresis in HTG-related AP.