Complications of therapeutic apheresis, including a fatal case with pulmonary vascular occlusion

A porcine model of hemodialyzer reactions: roles of complement activation and rinsing back of extracorporeal blood

Hemodialysis reactions (HDRs) resemble complement-activation-related pseudoallergy (CARPA) to certain i.v. drugs, for which pigs provide a sensitive model. On this basis, to better understand the mechanism of human HDRs, we subjected pigs to hemodialysis using polysulfone (FX CorDiax 40, Fresenius) or cellulose triacetate (SureFlux-15UX, Nipro) dialyzers, or Dialysis exchange-set without membranes, as control. Experimental endpoints included typical biomarkers of porcine CARPA; pulmonary arterial pressure (PAP), blood cell counts, plasma sC5b-9 and thromboxane-B2 levels. Hemodialysis (60 min) was followed by reinfusion of extracorporeal blood into the circulation, and finally, an intravenous bolus injection of the complement activator zymosan. The data indicated low-extent steady rise of sC5b-9 along with transient leukopenia, secondary leukocytosis and thrombocytopenia in the two dialyzer groups, consistent with moderate complement activation. Surprisingly, small changes in baseline PAP and plasma thromboxane-B2 levels during hemodialysis switched into 30%-70% sharp rises in all three groups resulting in synchronous spikes within minutes after blood reinfusion. These observations suggest limited complement activation by dialyzer membranes, on which a membrane-independent second immune stimulus was superimposed, and caused pathophysiological changes also characteristic of HDRs. Thus, the porcine CARPA model raises the hypothesis that a second "hit" on anaphylatoxin-sensitized immune cells may be a key contributor to HDRs.

Hemodynamic Tolerance and Plasma Volume Variations during Plasma Exchange

Little is known about mechanisms of systemic hypotension frequently reported during plasma exchange (PE). Type of substitution fluids may interfere with hemodynamic tolerance. In a prospective study, right heart catheterization was performed during 18 PE by filtration with isovolumic substitution. Blood volume was measured with 51Cr tagged erythrocytes and plasma volume (PV) calculated from hematocrit. Substitution fluids were either albumin (A; n = 9) or A + gelatin (A + G; n = 9). In both groups, PE induces significant (p < 0.01) decreases of mean arterial pressure: group A: - 21 ± 14%; group A + G: - 23 ± 15%; of pulmonary wedge pressure: group A: - 41 ± 33%; group A + G: - 36 ± 22%; of cardiac index: group A: - 38 ± 18%; group A + G: - 25 ± 15%. Plasma volume also decreases after PE: group A: - 13.5 ± 4%; group A + G: - 18.5 + 4%. None of the variations are significantly different between the two groups. So we think that substitution with albumin alone has no advantage for hemodynamic tolerance.

Treatment of pruritus in cholestatic jaundice by bilirubin- and bile acid-adsorbing resin column plasma perfusion

The efficacy of plasma perfusion through a new anionic resin, BR-350, for palliation of intractable pruritus secondary to intrahepatic cholestasis was studied in four patients. The treatment was given in a daily 2-h session on 3 consecutive days and was followed by repeated treatment periods each 3rd to 4th week. The patients experienced symptomatic improvement during the first treatment period, and the treatment was well tolerated. Adsorption of bile acids across the filter was efficient and resulted in a bile acid concentration gradient pre- to post-resin of 92%. Thus plasma perfusion through the ion resin BR-350 is an effective and safe treatment for symptomatic relief of intractable pruritus in cholestatic liver disease and may reduce hospitalization time and increase the quality of life.

Filtration of fresh frozen plasma used as substitution fluid in plasma exchange in order to remove microaggregates

Freshly melted fresh frozen plasma (FFP) contains a large number of particles smaller than 20 microns in diameter. These particulate materials (microaggregates) consist of aggregated triglyceride-rich lipoproteins (LA) and precipitable aggregates closely resembling fibrin (FA). Both LA and FA injected into a rat's tail vein were trapped in the lung and formed emboli in the pulmonary arterioles. To prevent the passage of these microaggregates into the systemic circulation, a new circuit was devised for plasma exchange containing a filter with a pore size of 0.2 microns. In 17 patients with fulminant hepatitis who received plasma exchange transfusions and subsequently died and were autopsied, the incidence of pulmonary complications was significantly lower in the 12 patients who received filtered FFP. According to these results, the possibility of pulmonary complications due to micro-embolism developed by microaggregates in FFP should be taken into account when a large amount of FFP is repeatedly infused into critically ill patients.

Therapeutic plasmapheresis and protein A immunoadsorption in malignancy: a brief review

Plasmapheresis is being used with considerable frequency in the management of malignant and non-malignant disorders. More recently, staphylococcal Protein A immunoadsorption has been employed in similar clinical situations. In patients with malignancy, plasmapheresis has been shown to produce alterations in plasma proteins, decrease circulating immune complexes, remove "specific" and "non-specific" blocking factors, change immune reactivity, and affect monocyte function. Partial responses have been reported in a small number of patients with carcinoma of lung, colon, and breast following plasmapheresis. In addition, there are reports of favorable responses in patients with melanoma, head and neck tumors, lymphomas, leukemias, and Kaposi's sarcoma in acquired immune deficiency. All these responses were partial and brief, and the treatment did not alter the course of the disease. Plasmapheresis has been useful in the management of hyperviscosity and occasionally of paraneoplastic syndromes. It may also have a role in the treatment of thrombotic thrombocytopenic purpura associated with mitomycin-C therapy. Protein A immunoadsorption, by which circulating immune complexes are selectively removed, can activate the complement system, increase blastogenic responses, and increase the natural killer cell activity. It has been shown to produce partial responses in breast and colon cancer, as well as Kaposi's sarcoma in acquired immune deficiency. It may have a useful role to play in the management of mitomycin-C-associated thrombotic thrombocytopenic purpura. Both plasmapheresis and Protein A immunoadsorption should be considered investigational interventions at this time. Toxicity of plasmapheresis, though uncommon, can be serious and may rarely be fatal. Toxicity of Protein A immunoadsorption is mild, consisting mainly of influenza-like symptoms and rash.

Plasmapheresis: technique and complications

Plasmapheresis has been used in an increasing number of diverse conditions over the past 15 years, and patients on intensive care units are sometimes so treated. This article reviews the principles, different techniques and refinements available, including the more specific methods of antibody removal, such as immunoadsorption. The vascular access, anticoagulation, choice of fluid replacement and monitoring requirements are discussed. The reported possible complications of plasmapheresis, relating both to the practical aspects of the procedure and to the effects of plasma removal and the replacement fluids, are reviewed.

Complications of plasma exchange in the treatment of polyarteritis nodosa and Churg-Strauss angiitis and the contribution of adjuvant immunosuppressive therapy: a randomized trial in 72 patients

We recorded side effects and other complications of 813 plasma exchanges used in early treatment of polyarteritis nodosa and Churg-Strauss angiitis in a prospective study of 72 patients (22-75 years old). All the patients were also treated with a corticosteroid (1 mg/kg/day), and half were included in a randomized trial of cyclophosphamide (2 mg/kg/day during 1 year). Centrifugation was used in 678 plasma exchange sessions (83.4%) and filtration in 128 (15.7%) (no data were available about the technique used in seven cases). The replacement fluid in 745 sessions was 4% albumin and in 115 was fresh-frozen plasma; eight patients received both (47 sessions). Two hundred and fifty-one complications were reported in 60 patients during 206 (25.3%) of the 813 completed exchanges; 47 sessions (5.8%) were temporarily stopped as a result of complications. The most common problems were technical difficulties (in 90 sessions), moderate or severe hypotension (in 52), and allergy to the replacement fluid (in 51). Hepatitis B antigen appeared in one patient. In four patients, plasma exchange was stopped permanently because of the severe side effects. No patient died during a session. Twelve of the 72 patients died during the study, six in each of the two groups. In the group treated by a combination of corticosteroid and plasma exchange, deaths were related to the deleterious effects of the disease itself and occurred after 12.8 +/- 11.1 months (1-26 months). In the group treated by the same combination plus cyclophosphamide, four of the six deaths were due to severe infections, which were related to leukopenia in three patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasmapheresis, a treatment modality for necrobiotic xanthogranuloma

A case of necrobiotic xanthogranuloma treated with plasmapheresis is reported. This entity is characterized by multiple inflammatory, ulcerative nodules and atrophic plaques with a xanthomatous quality that develop in conjunction with a paraproteinemia. Successful healing of ulcerated lesions and lowering of the paraproteinemia was achieved by plasmapheresis in our patient with necrobiotic xanthogranuloma when cytotoxic therapy failed.

Current status of plasmapheresis in toxicology

Although the elimination of specific toxins by the removal of all plasma constituents is a crude approach, further refinements of the technique should permit safer and more selective detoxification in the future. Currently the mainstay of treatment of intoxicated patients remains careful, aggressive, supportive care. Plasmapheresis should be considered as yet an unproven, hazardous form of therapy for the treatment of intoxication. Its main role should be confined to a research setting in which investigators attempt to develop more advanced and potentially useful apheresis techniques. Membrane plasmapheresis with subsequent on-line treatment of the plasma by sorbent may remove specific plasma solutes. The plasma may be perfused back to the patient without the need to use replacement fluids, thus avoiding many of the side effects of conventional exchange. Bile acids have been removed by circulating plasma over charcoal-coated glass beads, and several toxic substances were shown to be absorbed by perfusion over amberlite resin columns. Another productive area for future research includes the use of plasma exchange therapy for the treatment of acute endogenous intoxications. Recent examples include the treatment of severe preeclampsia, extensive rhabdomyolysis, and life-threatening bleeding in a hemophiliac with inhibitors to clotting factors. Although plasmapheresis in the management of intoxications is still an experimental technique, it may open the door to the treatment of previously intractable syndromes, both medical and toxicologic.

Therapeutic plasmapheresis and plasma exchange

Plasma exchange is a process in which large volumes of plasma, usually equivalent to one plasma volume, are exchanged with donor plasma or a plasma substitute. This permits the removal of antibody, immune complexes, inflammatory mediators, paraproteins, drugs, toxins, and other plasma constituents. Plasma exchange may also have an effect on the immune system by enhancing the function of the reticuloendothelial system, removing blocking antibody, increasing clearance of tumor cells, and making lymphocytes more vulnerable to immunosuppressive drugs. Over 100 diseases have been treated with plasma exchange with variable success. Results of controlled studies are less dramatic than those of earlier uncontrolled case reports. Reports of complications and even death have tempered initial enthusiasm. Now, over a decade since the initial promising reports began to appear in the literature, the role of plasma exchange remains undefined.

Role of plasmapheresis in primary biliary cirrhosis

Five patients with primary biliary cirrhosis and prolonged cholestasis underwent intensive plasmapheresis. The indications for plasmapheresis included intractable pruritus or hypercholesterolemia and xanthomatous neuropathy. Patients noted a rapid improvement of pruritus and fatigue which was sustained as long as plasmapheresis was continued. Cholesterol levels were lowered an average of 10.3 mmol/l and xanthomata were reduced in three of four patients. Two patients with painful neuropathy caused by xanthomata experienced relief of this symptom. The liver and spleen size were not affected by plasmapheresis, and activities of aminotransferases, alkaline phosphatase and titres of mitochondrial antibody remained unchanged. We conclude that plasmapheresis has a role in the therapeutic management of patients with advanced primary biliary cirrhosis who are disabled by the complications of pruritus, xanthomatous neuropathy, or hypercholesterolemia with xanthoma formation.