Current status of hemapheresis in the United States

Plasmapheresis in the University of Malaya Medical Centre, Malaysia

Over the past 3 decades, plasmapheresis has been used more extensively for a variety of neurological and hematological disorders. We undertook a retrospective review to ascertain its safety, efficacy, and factor(s) that predispose to poor outcome. We reviewed 117 plasma exchanges in 24 patients with a mean age of 43 +/- 15 years; half were male. A total of 79% of the patients had neurological diseases, and the most common were chronic inflammatory demyelinating polyneuropathy, Guillain-Barré syndrome, and myasthenic crisis. Plasmapheresis was effective in 79% of the patients, especially for neurological indications. Complications occurred in 23% of the exchanges affecting 58% of the patients. Most complications were mild; sepsis was the most common (9.4% of exchanges), especially catheter related sepsis (6%), rash (4.3%), and hypotension (4.3%). Only 2 (8%) patients had severe complications that required mechanical ventilation. There were 5 mortalities (21%), 3 due to sepsis and 2 due to myocardial ischemia and arrhythmia, none of which occurred within 48 h of the last exchange. Patients with poor renal function had higher mortality. Overall, our figures agree with those from other institutions and indicate that plasma exchange is an effective and safe procedure, especially for a variety of neuroimmunological conditions.

Physician coverage of therapeutic apheresis

A "snapshot" survey of physician coverage for evaluation and supervision of therapeutic apheresis procedures shows significant variation in current clinical practice between 39 blood center-and 41 non-blood center-based programs. Whereas 56% of blood center-based programs usually require physician's "in person" evaluation of the patient, 86% of non-blood center programs do (P < .005). Similarly, non-blood center-based programs were more likely to have physicians on the premises to supervise first and subsequent procedures and to bill separately for medical coverage. These differences were unrelated to location of the procedure (in hospital, blood bank, outpatient department, or other), the size of the program, or any information provided on adverse reactions.

Complications of therapeutic plasma exchange: a recent assessment

The use of therapeutic plasma exchange, particularly for management of patients with neurological disorders, has steadily increased in our hospital since 1991, thus highlighting the need for continuing quality assurance of these services. We have reviewed the hemapheresis records of all 381 therapeutic plasma exchange procedures performed on a total of 63 patients from January 1991 through December 1992. Patients were referred for therapeutic plasma exchange for the following indications: acute Guillain-Barre syndrome, 31 patients (49.2%); chronic inflammatory demyelinating polyneuropathy, 15 patients (23.8%); myasthenia gravis, five patients (7.94%); paraproteinemic neuropathy, five patients (7.94%); thrombotic microangiopathies, six patients (9.52%) and Goodpasture syndrome, one patient (1.6%). Overall, 89% of patients were treated for neurological disorders. Complications of plasma exchange were noted during 17% (n = 65) of procedures involving 49% (n = 31) of patients treated. Approximately 91% of complications were classified as mild (55.4%) or moderately severe (35.4%) and did not prevent successful completion of the procedure. These were largely related to use of citrate-containing anticoagulants and additionally may have reflected the autonomic instability of many of the neuropathy patients. All four (6.15%) severe complications and one of two fatalities were related to the use of central venous access catheters. We conclude that therapeutic plasma exchange can be performed safely with acceptable toxicity caused by mild and moderately severe complications. Major complications may be minimized by careful management of central venous catheters when required for access.