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Mina-Osorio P, Tran MH, Habib AA. Therapeutic Plasma Exchange Versus FcRn Inhibition in Autoimmune Disease. Transfus Med Rev 2024; 38:150767. [PMID: 37867088 DOI: 10.1016/j.tmrv.2023.150767] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 10/24/2023]
Abstract
Therapeutic plasma exchange (TPE or PLEX) is used in a broad range of autoimmune diseases, with the goal of removing autoantibodies from the circulation. A newer approach for the selective removal of immunoglobulin G (IgG) antibodies is the use of therapeutic molecules targeting the neonatal Fc receptor (FcRn). FcRn regulates IgG recycling, and its inhibition results in a marked decrease in circulating autoantibodies of the IgG subtype. The difference between FcRn inhibition and PLEX is often questioned. With anti-FcRn monoclonal antibodies (mAbs) and fragments only recently entering this space, limited data are available regarding long-term efficacy and safety. However, the biology of FcRn is well understood, and mounting evidence regarding the efficacy, safety, and potential differences among compounds in development is available, allowing us to compare against nonselective plasma protein depletion methods such as PLEX. FcRn inhibitors may have distinct advantages and disadvantages over PLEX in certain scenarios. Use of PLEX is preferred over FcRn inhibition where removal of antibodies other than IgG or when concomitant repletion of missing plasma proteins is needed for therapeutic benefit. Also, FcRn targeting has not yet been studied for use in acute flares or crisis states of IgG-mediated diseases. Compared with PLEX, FcRn inhibition is associated with less invasive access requirements, more specific removal of IgG versus other immunoglobulins without a broad impact on circulating proteins, and any impacts on other therapeutic drug levels are restricted to other mAbs. In addition, the degree of IgG reduction is similar with FcRn inhibitors compared with that afforded by PLEX. Here we describe the scientific literature regarding the use of PLEX and FcRn inhibitors in autoimmune diseases and provide an expert discussion around the potential benefits of these options in varying clinical conditions and scenarios.
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Affiliation(s)
| | - Minh-Ha Tran
- Department of Pathology, School of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Ali A Habib
- Department of Neurology, School of Medicine, University of California, Irvine, Irvine, CA, USA
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2
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Sanchez AP, Ward DM, Cunard R. Therapeutic plasma exchange in the intensive care unit: Rationale, special considerations, and techniques for combined circuits. Ther Apher Dial 2022; 26 Suppl 1:41-52. [PMID: 36468345 DOI: 10.1111/1744-9987.13814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 02/07/2022] [Indexed: 12/11/2022]
Abstract
Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique with proven efficacy in a variety of conditions, including in the intensive care setting. It is not uncommon for a critically ill patient to require more than one extracorporeal procedure in addition to TPE. This review focuses on the combination of TPE with other extracorporeal circuits in a critical care setting via a single vascular access (either in-series, parallel, or a hybrid mode) which is often referred to as performing procedures "in tandem." Authors performed literature review via pubmed.gov using search terms: plasma exchange, plasmapheresis, apheresis, tandem circuits, combined circuits, critical care, ICU, CRRT, hemodialysis, and ECMO. Thirty-eight English-language, peer-reviewed papers were appraised that satisfied the content of this review on techniques for combining circuits with plasma exchange, as well as describing the advantages of tandem procedures and potential complications that can arise. Performing these procedures simultaneously can be advantageous in reducing total procedure and staffing time, avoiding placement of additional central lines, reducing overall need for anticoagulation, and limiting multiple blood primes in certain populations. However, the described combined circuits are complex, associated with higher complications, and require a skilled team to understand and mitigate the potential complications associated with these combined procedures.
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Affiliation(s)
- Amber P Sanchez
- Division of Nephrology and Hypertension, University of California San Diego, San Diego, California, USA
| | - David M Ward
- Division of Nephrology and Hypertension, University of California San Diego, San Diego, California, USA
| | - Robyn Cunard
- Division of Nephrology and Hypertension, University of California San Diego, San Diego, California, USA.,Veterans Affairs San Diego Healthcare System, San Diego, California, USA
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3
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Moranne O, Ion IM, Cezar R, Messikh Z, Prelipcean C, Chkair S, Thouvenot E, Tran TA, Corbeau P, Chevallier T. Protocol of comparison of the effects of single plasma exchange and double filtration plasmapheresis on peripheral lymphocyte phenotypes in patients with Chronic Inflammatory Demyelinating Polyradiculoneuropathy: a monocentric prospective study with single-case experimental design. BMC Neurol 2022; 22:293. [PMID: 35931957 PMCID: PMC9354281 DOI: 10.1186/s12883-022-02816-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP), a rare disorder affecting young adults, causes gradual weakness of the limbs, areflexia and impaired sensory function. New CIDP phenotypes without pathogenic antibodies but with modified cell profiles have been described. Treatments include corticotherapy, intravenous immunoglobulins, and plasmapheresis but the latter's action mechanisms remain unclear. Plasmapheresis supposedly removes toxic agents like antibodies from plasma but it is uncertain whether it has an immune-modulating effect. Also, the refining mechanisms of the two main plasmapheresis techniques-single plasma exchange and double filtration plasmapheresis (DFPP) - are different and unclear. This study aims to compare the evolution of peripheral lymphocyte profiles in patients with CIDP according to their treatment (single centrifugation plasmapheresis or DFPP) to better grasp the action mechanisms of both techniques. METHOD In this proof-of-concept, monocentric, prospective, Single-Case Experimental Design study, 5 patients are evaluated by alternating their treatment type (single plasma exchange or DFPP) for 6 courses of treatment after randomization to their first treatment type. Each course of treatment lasts 2-4 weeks. For single plasma exchange, 60 ml/kg plasma will be removed from the patient and replaced with albumin solutes, with a centrifugation method to avoid the immunological reaction caused by the membrane used with the filtration method. For DFPP, 60 ml/kg plasma will be removed from the patient with a plasma separator membrane, then processed via a fractionator membrane to remove molecules of a greater size than albumin before returning it to the patient. This technique requires no substitution solutes, only 20 g of albumin to replace what would normally be lost during a session. The primary outcome is the difference between the two plasmapheresis techniques in the variation of the TH1/TH17 ratio over the period D0H0-D0H3 and D0H0-D7. Secondary outcomes include the variation in lymphocyte subpopulations at each session and between therapeutic plasmapheresis techniques, the clinical evolution, tolerance and cost of treatments. DISCUSSION Understanding the action mechanisms of single plasma exchange and DFPP will help us to offer the right treatment to each patient with CIPD according to efficacy, tolerance and cost. TRIAL REGISTRATION ClinicalTrials.gov under the no. NCT04742374 and date of registration 10 December 2020.
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Affiliation(s)
- O Moranne
- Service de Nephrologie Dialyse Apherese, Hôpital Universitaire de Nîmes, Nîmes, France. .,Desbrest Institute of Epidemiology and Public Health UMR, INSERM - University of Montpellier, Montpellier, France.
| | - I M Ion
- Service de Neurologie, Hôpital Universitaire de Nîmes, Nîmes, France
| | - R Cezar
- Department of Immunology, IRMB, INSERM U1183-Montpellier University, University Hospital of Nîmes, 80 Rue Augustin Fliche, 34295, Montpellier, FrancePlace du Pr Debré, 30029, Nîmes, France
| | - Z Messikh
- Service de Nephrologie Dialyse Apherese, Hôpital Universitaire de Nîmes, Nîmes, France
| | - C Prelipcean
- Service de Nephrologie Dialyse Apherese, Hôpital Universitaire de Nîmes, Nîmes, France
| | - S Chkair
- Department of Biostatistics, Epidemiology, IDIL (Medical Devices Evaluation), Public Health Innovation in Methodology, Nimes University Hospital, University of Montpellier, Nimes, France
| | - E Thouvenot
- Service de Neurologie, Hôpital Universitaire de Nîmes, Nîmes, France.,Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
| | - Tu Anh Tran
- Department of Pediatrics, Nimes University Hospital, Nimes, France INSERM U 1183, IRMB, Montpellier University, Montpellier, France
| | - P Corbeau
- Department of Immunology, Nimes University Hospital, University of Montpellier, Nimes, France
| | - T Chevallier
- Desbrest Institute of Epidemiology and Public Health UMR, INSERM - University of Montpellier, Montpellier, France.,Department of Biostatistics, Epidemiology, IDIL (Medical Devices Evaluation), Public Health Innovation in Methodology, Nimes University Hospital, University of Montpellier, Nimes, France
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Total Plasma Exchange in Neuromuscular Junction Disorders—A Single-Center, Retrospective Analysis of the Efficacy, Safety and Potential Diagnostic Properties in Doubtful Diagnosis. J Clin Med 2022; 11:jcm11154383. [PMID: 35955999 PMCID: PMC9369332 DOI: 10.3390/jcm11154383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 01/14/2023] Open
Abstract
Neuromuscular junction disorders (NJDs) are a heterogeneous group of diseases including myasthenia gravis (MG). In some cases, patients are present with myasthenic symptoms without evidence of autoimmune antibodies, making diagnosis challenging. Total plasma exchange (TPE) has proven efficacy in NJDs. The objective is to describe the safety and efficacy of TPE in NJD patients with questionable disease activity or uncertain diagnosis in order to assess the diagnostic potential of TPE. We report an observational, retrospective cohort study of clinical routine data. All the data were derived from the electronic medical records of the Department of Neurology at University Hospital Essen. We searched for patients with NJDs between 1 July 2018 and 30 June 2021. Of the 303 patients who presented to the department with NJDs, 20 were treated with TPE; 9 patients did not show a measurable benefit from TPE (45%), 6 of whom were diagnosed with seronegative MG. Of these, 3 (50%) had long-standing ocular symptoms. There were decreases in the mean arterial pressure, hemoglobin, hematocrit and fibrinogen during treatment, which were not considered clinically relevant. In (seronegative) myasthenic patients, TPE may help to verify an uncertain diagnosis or to reveal possible muscle damage, allowing unnecessary therapy to be avoided.
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Keklik M, Çelik S, Yıldızhan E. Comparison of centrifugal and membrane filtration modalities on therapeutic plasma exchange. J Clin Apher 2022; 37:217-222. [PMID: 34978347 DOI: 10.1002/jca.21961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/21/2021] [Accepted: 12/21/2021] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Muzaffer Keklik
- Department of Hematology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Serhat Çelik
- Department of Hematology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Esra Yıldızhan
- Department of Hematology, Kayseri City Hospital, Kayseri, Turkey
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Chegini A, Fani P, Samiee S, Shaiegan M, Hajati E, Maghari A. The effect of platelet apheresis collection on some immunological factors in donors using two different apheresis devices. Ther Apher Dial 2021; 26:1040-1046. [PMID: 34859594 DOI: 10.1111/1744-9987.13771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The aim of this study was to evaluate and compare two different apheresis and changes in some immunological factors in donors. MATERIAL AND METHODS The cross-sectional study was performed from January 2017 to September 2018. Fifty six male blood donors were randomly divided into two groups. CD4, CD8, and CD25 markers by flow cytometry, and TGFBeta by real-time polymerase chain reaction (RT-PCR) method were done before and 7 days after the apheresis procedure. Independent Sample t-test, Mann-Whitney U Test, Wilcoxon signed ranked test, and Fisher exact test were used. RESULTS WBC in MCS+ group after donation is significantly higher than before donation (P < 0.05) but no significant difference was seen between MCS+ and Trima groups in these two indicators. But in CD4, CD25, and TGFBeta, there was no significant difference between the two groups. CONCLUSION There was no significant difference on CD4, CD25, and TGFBeta gene 7 days after donation.
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Affiliation(s)
- Azita Chegini
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Parvaneh Fani
- Immunohematology Department, Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Shahram Samiee
- Immunohematology Department, Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Mojgan Shaiegan
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Esmerdis Hajati
- Immunohematology Department, Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Amirhossein Maghari
- Department of Family Health, Social Determinants of Health Research Center (SDHRC), Ardebil University of Medical Sciences, Ardebil, Iran
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Duy Nguyen BT, Nguyen Thi HY, Nguyen Thi BP, Kang DK, Kim JF. The Roles of Membrane Technology in Artificial Organs: Current Challenges and Perspectives. MEMBRANES 2021; 11:239. [PMID: 33800659 PMCID: PMC8065507 DOI: 10.3390/membranes11040239] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/20/2021] [Accepted: 03/20/2021] [Indexed: 02/07/2023]
Abstract
The recent outbreak of the COVID-19 pandemic in 2020 reasserted the necessity of artificial lung membrane technology to treat patients with acute lung failure. In addition, the aging world population inevitably leads to higher demand for better artificial organ (AO) devices. Membrane technology is the central component in many of the AO devices including lung, kidney, liver and pancreas. Although AO technology has improved significantly in the past few decades, the quality of life of organ failure patients is still poor and the technology must be improved further. Most of the current AO literature focuses on the treatment and the clinical use of AO, while the research on the membrane development aspect of AO is relatively scarce. One of the speculated reasons is the wide interdisciplinary spectrum of AO technology, ranging from biotechnology to polymer chemistry and process engineering. In this review, in order to facilitate the membrane aspects of the AO research, the roles of membrane technology in the AO devices, along with the current challenges, are summarized. This review shows that there is a clear need for better membranes in terms of biocompatibility, permselectivity, module design, and process configuration.
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Affiliation(s)
- Bao Tran Duy Nguyen
- Department of Energy and Chemical Engineering, Incheon National University, Incheon 22012, Korea; (B.T.D.N.); (H.Y.N.T.); (B.P.N.T.)
| | - Hai Yen Nguyen Thi
- Department of Energy and Chemical Engineering, Incheon National University, Incheon 22012, Korea; (B.T.D.N.); (H.Y.N.T.); (B.P.N.T.)
| | - Bich Phuong Nguyen Thi
- Department of Energy and Chemical Engineering, Incheon National University, Incheon 22012, Korea; (B.T.D.N.); (H.Y.N.T.); (B.P.N.T.)
| | - Dong-Ku Kang
- Department of Chemistry, Incheon National University, Incheon 22012, Korea
| | - Jeong F. Kim
- Department of Energy and Chemical Engineering, Incheon National University, Incheon 22012, Korea; (B.T.D.N.); (H.Y.N.T.); (B.P.N.T.)
- Innovation Center for Chemical Engineering, Incheon National University, Incheon 22012, Korea
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Noble J, Metzger A, Naciri Bennani H, Daligault M, Masson D, Terrec F, Imerzoukene F, Bardy B, Fiard G, Marlu R, Chevallier E, Janbon B, Malvezzi P, Rostaing L, Jouve T. Apheresis Efficacy and Tolerance in the Setting of HLA-Incompatible Kidney Transplantation. J Clin Med 2021; 10:jcm10061316. [PMID: 33806743 PMCID: PMC8005077 DOI: 10.3390/jcm10061316] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/07/2021] [Accepted: 03/17/2021] [Indexed: 12/23/2022] Open
Abstract
Nearly 18% of patients on a waiting list for kidney transplantation (KT) are highly sensitized, which make access to KT more difficult. We assessed the efficacy and tolerance of different techniques (plasma exchanges [PE], double-filtration plasmapheresis [DFPP], and immunoadsorption [IA]) to remove donor specific antibodies (DSA) in the setting of HLA-incompatible (HLAi) KT. All patients that underwent apheresis for HLAi KT within a single center were included. Intra-session and inter-session Mean Fluorescence Intensity (MFI) decrease in DSA, clinical and biological tolerances were assessed. A total of 881 sessions were performed for 45 patients: 107 DFPP, 54 PE, 720 IA. The procedures led to HLAi KT in 39 patients (87%) after 29 (15–51) days. A higher volume of treated plasma was associated with a greater decrease of inter-session class I and II DSA (p = 0.04, p = 0.02). IA, PE, and a lower maximal DSA MFI were associated with a greater decrease in intra-session class II DSA (p < 0.01). Safety was good: severe adverse events occurred in 17 sessions (1.9%), more frequently with DFPP (6.5%) p < 0.01. Hypotension occurred in 154 sessions (17.5%), more frequently with DFPP (p < 0.01). Apheresis is well tolerated (IA and PE > DFPP) and effective at removing HLA antibodies and allows HLAi KT for sensitized patients.
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Affiliation(s)
- Johan Noble
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
- University Grenoble Alpes, 38000 Grenoble, France
| | - Antoine Metzger
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Hamza Naciri Bennani
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Melanie Daligault
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Dominique Masson
- HLA Laboratory—Établissement Français du Sang-EFS-, 38000 Grenoble, France; (D.M.); (B.B.)
| | - Florian Terrec
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Farida Imerzoukene
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Beatrice Bardy
- HLA Laboratory—Établissement Français du Sang-EFS-, 38000 Grenoble, France; (D.M.); (B.B.)
| | - Gaelle Fiard
- Urology Department, University Hospital Grenoble, 38000 Grenoble, France;
- TIMC-IMAG, Grenoble INP, CNRS, University Grenoble Alpes, F-38000 Grenoble, France
| | - Raphael Marlu
- Haemostasis Laboratory, University Hospital Grenoble, 38000 Grenoble, France;
| | - Eloi Chevallier
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Benedicte Janbon
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
- University Grenoble Alpes, 38000 Grenoble, France
- Correspondence: ; Tel.: +33-476768945; Fax: +33-476765263
| | - Thomas Jouve
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38000 Grenoble, France; (J.N.); (A.M.); (H.N.B.); (M.D.); (F.T.); (F.I.); (E.C.); (B.J.); (P.M.); (T.J.)
- University Grenoble Alpes, 38000 Grenoble, France
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Sanchez AP, Balogun RA. Therapeutic Plasma Exchange in the Critically Ill Patient: Technology and Indications. Adv Chronic Kidney Dis 2021; 28:59-73. [PMID: 34389138 DOI: 10.1053/j.ackd.2021.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/20/2021] [Accepted: 03/17/2021] [Indexed: 12/17/2022]
Abstract
Therapeutic plasma exchange (TPE) is frequently the most common Apheresis Medicine technique used for extracorporeal therapy of a wide variety of renal, neurological, hematological, and other clinical indications. Many of these clinical indications require intensive care during critical illness. Conventional TPE uses one of two main technical methods to achieve the goal of removing known disease mediators from the plasma: using centrifugal forces to separate and remove components of blood, or a membrane filtration method that separates plasma from the cellular components of blood. The following review discusses the basic principles of TPE, the technological aspects, and relevant clinical scenarios encountered in the intensive care unit, including relevant guidelines and recommendations from the American Society for Apheresis.
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10
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Liou AA, Skiver BM, Yates E, Persad P, Meyer D, Farland AM, Rocco MV. Acute Thrombotic Microangiopathy and Cortical Necrosis Following Administration of Alemtuzumab: A Case Report. Am J Kidney Dis 2018; 73:615-619. [PMID: 30528935 DOI: 10.1053/j.ajkd.2018.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 09/12/2018] [Indexed: 12/11/2022]
Abstract
Alemtuzumab, a humanized monoclonal antibody that targets CD52 antigens on lymphocytes and monocytes, has shown efficacy in preventing relapse in relapsing-remitting multiple sclerosis. Despite known severe (yet rare) renal side effects such as anti-glomerular basement membrane disease and membranous glomerulopathy, to our knowledge, alemtuzumab has never been documented to cause drug-induced thrombotic microangiopathy. We describe a 39-year-old woman with relapsing-remitting multiple sclerosis who developed acute kidney injury requiring renal replacement therapy after 1 dose of alemtuzumab, as well as microangiopathic hemolytic anemia and thrombocytopenia. Pathologic examination of a kidney biopsy specimen demonstrated extensive cortical necrosis and arteriolar fibrin thrombi with nonspecific immunofluorescence staining of immunoglobulin M and C3 and absence of immune deposits on electron microscopy. These findings were consistent with the diagnosis of acute thrombotic microangiopathy. She received dexamethasone and underwent plasmapheresis, which was unsuccessful at removing alemtuzumab. The patient received renal replacement therapy for approximately 7 weeks, followed by slow recovery of kidney function that returned close to her baseline.
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Affiliation(s)
- Ashley A Liou
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Brent M Skiver
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Eric Yates
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Paul Persad
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
| | - David Meyer
- Triad Neurological Associates, Winston-Salem, NC
| | - Andrew M Farland
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael V Rocco
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
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Lower In-Hospital Mortality with Plasma Exchange than Plasmapheresis in a Subgroup Analysis of 374 Lupus Patients. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9707932. [PMID: 29854814 PMCID: PMC5954964 DOI: 10.1155/2018/9707932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/22/2018] [Accepted: 03/26/2018] [Indexed: 11/17/2022]
Abstract
Background Apheresis treatment includes plasmapheresis (PP) and plasma exchange (PE), and these terms are commonly used interchangeably. Nevertheless, the two procedures are carried out differently. The aims of this study were to investigate the mortality rate of patients who underwent therapeutic apheresis and compare the mortality rate between PP and PE. Methods We conducted a medical chart review retrospective study. All identified subjects (n = 436) were over 20 years old with at least one ICD-9-CM intervention code plasmapheresis or plasma exchange and at least one diagnosis code with rheumatic disease. All of them were hospitalized to Chang Gung Memorial Hospital between 1st of January, 2000, and 31st of December, 2014. Results 436 nonoverlapping patients had never received PE and/or PP before 1 Jan, 2000. Among all the patients, 350 received PE, 63 received PP, and 23 received both therapies. Female patients accounted for 85.09% of patients. The overall mortality rate was 4.65% in the PE subgroup, 4.76% with combination therapy, and 13.46% in the PP subgroup. There were 374 patients diagnosed as SLE, which is the majority of overall patients who received PE and/or PE. In multivariate analysis, PE was the sole independent factor predictor of survival in SLE subgroup patients (p = 0.02, exp(B) = 0.314, 95% CI 0.12–0.81). Conclusions We showed that both PP and PE were used in treating a variety of autoimmune disorders. Plasmapheresis was preferentially carried out in patients with peripheral neuropathy. In 374 lupus patients treated with either PE or PP, PE is superior to PP in reducing in-hospital mortality.
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Scagnelli AM, Walton SA, Liu CC, Acierno MJ. Effects of therapeutic plasma exchange on serum immunoglobulin concentrations in a dog with refractory immune-mediated hemolytic anemia. J Am Vet Med Assoc 2018; 252:1108-1112. [DOI: 10.2460/javma.252.9.1108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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13
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Amoureux MC, Rajapakse N, Hegyi E, Le D, Grandics P, Szathmary S. Endotoxin Removal from Whole Blood by a Novel Adsorption Resin: Efficiency and Hemocompatibility. Int J Artif Organs 2018; 27:480-7. [PMID: 15291078 DOI: 10.1177/039139880402700606] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The structural component of Gram- bacteria, endotoxin (ET), induces the release of endogenous mediators of sepsis. Attempts to remove these downstream molecules in vivo, have not improved survival. However, extracorporeal strategies such as continuous renal replacement therapy or therapeutic plasmapheresis have shown benefit. We are presenting an affinity-based extracorporeal technology for the removal of ET from whole blood. The small-scale device contains an adsorbent that removed 75% of ET present in whole blood. This affinity resin displayed good hemocompatibility regarding the coagulation pathway. Minimal platelet, neutrophil and complement activation were observed. There was also no evidence of consumption of coagulation factors or cell loss. In as much as ET participates in both the inflammatory and coagulation abnormalities in sepsis, this method represents an efficient and hemocompatible way to remove ET from whole blood, which, in an extracorporeal setting, may improve the outcome of sepsis.
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Raghavan R, Shawar S. Mechanisms of Drug-Induced Interstitial Nephritis. Adv Chronic Kidney Dis 2017; 24:64-71. [PMID: 28284381 DOI: 10.1053/j.ackd.2016.11.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/01/2016] [Accepted: 11/03/2016] [Indexed: 11/11/2022]
Abstract
Drug-induced acute interstitial nephritis (DI-AIN) is a drug hypersensitivity reaction (DHR) that manifests 7 to 10 days after exposure to the culprit drug. DHRs account for fewer than 15% of reported adverse drug reactions. The kidneys are susceptible to DHR because: (1) the high renal blood flow whereby antigens are filtered, secreted, or concentrated, and (2) it is a major site of excretion for drugs and drug metabolites. More than 250 different drugs from various classes have been incriminated as causative agents of DI-AIN, the third most common cause of acute kidney injury in the hospital. DI-AIN must be differentiated from drug-induced nephrotoxic acute tubular necrosis because of their differing pathophysiology and treatment. DI-AIN begins with antigen processing and presentation to local dendritic cells. The dendritic cells activate T cells, and the subsequent effector phase of the immune response is mediated by various cytokines. Incriminated antigenic mechanisms include response to a conjugation product of the drug or its metabolite with a host protein (eg, beta-lactam or sulfonamide antibiotic) or the direct binding of the drug to a particular host allele to elicit a hypersensitivity response (eg, certain anti-epileptic drugs). If the offending drug is not identified and discontinued in a timely manner, irreversible fibrosis and chronic kidney disease will occur. The core structure of each drug or its metabolite is an antigenic determinant, and the host interaction is termed the structure-activity relationship. Differing structure-activity relationships accounts for effect, hypersensitivity, and cross-reactivity among and between classes. The essence of management of DI-AIN lies with the four sequential steps: anticipation, diagnosis, treatment, and prevention. Corticosteroids are used in the treatment of DI-AIN because of their potent anti-inflammatory effects on T cells and eosinophils. Anticipation and prevention require notifying the patient that DI-AIN is an idiosyncratic, hypersensitivity reaction that recurs on re-exposure, and the drug should be avoided.
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Kes P, Janssens ME, Bašić‐Jukić N, Kljak M. A randomized crossover study comparing membrane and centrifugal therapeutic plasma exchange procedures. Transfusion 2016; 56:3065-3072. [DOI: 10.1111/trf.13850] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 07/28/2016] [Accepted: 08/01/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Petar Kes
- Department of Nephrology, Arterial Hypertension, Dialysis and Kidney TransplantationUniversity Hospital Centre Zagreb, and Faculty of Medicine, University of ZagrebZagreb Croatia
| | | | - Nikolina Bašić‐Jukić
- Department of Nephrology, Arterial Hypertension, Dialysis and Kidney TransplantationUniversity Hospital Centre Zagreb, and Faculty of Medicine, University of ZagrebZagreb Croatia
| | - Milića Kljak
- Department of Nephrology, Arterial Hypertension, Dialysis and Kidney TransplantationUniversity Hospital Centre Zagreb, and Faculty of Medicine, University of ZagrebZagreb Croatia
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16
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Handschel D, Etienne Janssens M, Gericke M, De Reys S, Borberg H. Comparative evaluation of a heparin-citrate anticoagulation for LDL-apheresis in two primary apheresis systems. J Clin Apher 2016; 32:319-328. [DOI: 10.1002/jca.21512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 08/08/2016] [Accepted: 09/09/2016] [Indexed: 11/08/2022]
Affiliation(s)
| | | | - Marion Gericke
- Department of Scientific Services and Support, Terumo BCT; Zaventem Belgium
| | - Stef De Reys
- Department of Scientific Services and Support, Terumo BCT; Zaventem Belgium
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17
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Linenberger ML, Price TH. Use of Cellular and Plasma Apheresis in the Critically Ill Patient: Part 1: Technical and Physiological Considerations. J Intensive Care Med 2016; 20:18-27. [PMID: 15665256 DOI: 10.1177/0885066604271394] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Apheresis is the process of separating the blood and removing or manipulating a cellular or plasma component for therapeutic benefit. An apheresis procedure, or series of procedures, may be indicated in the critical care setting as primary or adjunctive therapy for certain hematologic, neurologic, renal, and autoimmune/ rheumatologic disorders. Optimal management of severely ill patients undergoing apheresis requires a working knowledge of the technical, methodological, and therapeutic considerations. These considerations include instrument hardware and separation methods, vascular access requirements, hemodynamic and hemostatic effects of the procedures, exposure to anticoagulants and homologous blood products, physiological variables affecting blood/plasma processing efficiency, and therapeutic endpoints for specific indications. Part 1 of this review will discuss each of those technological considerations and the basic physiological principles that guide this form of therapy. Part 2 of this series will deal with the clinical indications and applications for specific disorders that are most likely to affect patients in the intensive care unit.
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18
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Gashti CN. Membrane-based Therapeutic Plasma Exchange: A New Frontier for Nephrologists. Semin Dial 2016; 29:382-90. [PMID: 27062015 DOI: 10.1111/sdi.12506] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Therapeutic plasma exchange has long been utilized to manage a variety of immune-mediated diseases. The underlying principle is the removal of a circulating pathogenic substance from the plasma and substitution with a replacement fluid. Different methodologies of plasma separation include the use of centrifuge, which relies on the variation in the specific gravity of blood components, and membrane-based separation, which relies on particle size. With advancements in technology and clinical insight into disease pathophysiology, membrane technology has become more biocompatible, safer, and more adaptable to conventional hemodialysis and hemofiltration machines. As such, nephrologists, who are familiar with management of extracorporeal blood purification systems, are increasingly involved with membrane-based plasma separation. This review aims to highlight the technical aspects of membrane-based separation, review the prescription for therapy, and draw comparisons with the centrifuge-based technique when applicable.
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Affiliation(s)
- Casey N Gashti
- Section of Nephrology, Department of Medicine, Rush University Medical Center, Chicago, Illinois.
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19
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Ghio M, Contini P, Ansaldi F, Ubezio G, Setti M, Risso M, Tripodi G. Immunomodulation due to plasma or plasma-platelet apheresis donation: Events occurring during donation procedures. J Clin Apher 2014; 30:204-11. [DOI: 10.1002/jca.21362] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 07/14/2014] [Accepted: 09/16/2014] [Indexed: 12/27/2022]
Affiliation(s)
- Massimo Ghio
- Department of Internal Medicine; I.R.C.C.S. “A.O.U. San Martino-IST,”; Genova Italy
- University of Genoa; Viale Benedetto XV, 6 16132 Genova Italy
| | - Paola Contini
- Department of Internal Medicine; I.R.C.C.S. “A.O.U. San Martino-IST,”; Genova Italy
- University of Genoa; Viale Benedetto XV, 6 16132 Genova Italy
| | - Filippo Ansaldi
- University of Genoa; Viale Benedetto XV, 6 16132 Genova Italy
- Department of Health Sciences; I.R.C.C.S. “A.O.U. San Martino-IST,”; Genova Italy
| | - Gianluca Ubezio
- Department of Internal Medicine; I.R.C.C.S. “A.O.U. San Martino-IST,”; Genova Italy
- University of Genoa; Viale Benedetto XV, 6 16132 Genova Italy
| | - Maurizio Setti
- Department of Internal Medicine; I.R.C.C.S. “A.O.U. San Martino-IST,”; Genova Italy
- University of Genoa; Viale Benedetto XV, 6 16132 Genova Italy
| | - Marco Risso
- Immunohematology and Transfusion Centre; Institute Giannina Gaslini; Genova Italy
| | - Gino Tripodi
- Immunohematology and Transfusion Centre; Institute Giannina Gaslini; Genova Italy
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20
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Nakajima H, Kaneko S, Takano T, Hoshino T, Sato Y, Kawase T, Tsukamoto Y. Analysis of protein removal properties during cryofiltration apheresis using the Evaflux-5A plasma fractionator in a patient with hepatitis C virus-associated cryoglobulinemic glomerulonephritis. Ther Apher Dial 2014; 18:258-64. [PMID: 24965292 DOI: 10.1111/1744-9987.12213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Cryofiltration (CF) is a technique in which separated plasma is chilled before being subjected to a plasma fractionator (PF), leading to cryoglobulin precipitation or cryogel formation. In CF using the Evaflux-5A as the PF, there is no consensus on the necessity of albumin supplementation, and when or how often the PF column should be washed. We analyzed the sieving effects of various solutes (albumin, IgG, IgM, LDL, HCV-RNA, and cryoglobulin) depending on transmembrane pressure (TMPPF ) during CF using the Evaflux-5A in a patient with hepatitis C virus-associated cryoglobulinemic glomerulonephritis. Five CF treatments were initially performed and a sixth one later, at disease recurrence. Quantitative detection of cryoglobulin and a marked rise in TMPPF to 400 mm Hg were observed only at the first and sixth treatment, and albumin losses during these treatments were very high, at 16.8 g, and 14.6 g, respectively, while those of others (from the second to fifth) were 6.7 g, 6.4 g, 5.9 g, and 7.0 g, respectively. The sieving coefficients (SCs) of both albumin and IgG were stable (0.8-1.0) at TMPPF < 200 mm Hg, but significantly decreased at TMPPF ≥ 200 mm Hg (P < 0.01). The SC of IgM tended to decrease at TMPPF ≥ 200 mm Hg, but not significantly, while that of LDL was zero regardless of the TMPPF . Albumin loss per treatment likely depends on degree of TMPPF rise, which is mainly affected by the patient's cryoglobulinemic status. In CF using Evaflux-5A, washing the PF column to keep TMPPF < 200 mm Hg during treatment may be a recommended for selective removal and albumin salvage.
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Affiliation(s)
- Hirofumi Nakajima
- Department of Clinical Engineering, Itabashi Chuo Medical Center, Tokyo, Japan
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Abstract
The initial description of therapeutic plasma exchange (TPE) in an animal model was published almost 100 years ago. Since that time, this treatment has been applied to a wide variety of diseases but limited research has been published examining the mechanisms of action of TPE. The therapeutic effects of TPE could include the removal of pathological substances from the blood, such as monoclonal paraproteins and autoantibodies, as well as the replacement of deficient plasma components when plasma is used as a replacement fluid. Beyond these potential mechanisms, other possible mechanisms include possible alterations in lymphocyte proliferation and function that could sensitize these cells to immunosuppressant and chemotherapeutic agents and alterations in the immune system including changes in B and T cell numbers and activation, increased T suppressor function, and alteration in T-helper cell type 1/2 (Th1/Th2) ratio. Much remains unknown about the mechanisms of action of TPE, indicating a need for basic research into this therapy.
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Affiliation(s)
- Hollie M Reeves
- Department of Pathology - Clinical, University Hospitals Case Medical Center, Cleveland, OH, USA
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22
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Sanchez AP, Cunard R, Ward DM. The selective therapeutic apheresis procedures. J Clin Apher 2013; 28:20-9. [PMID: 23420592 DOI: 10.1002/jca.21265] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Accepted: 01/15/2013] [Indexed: 12/12/2022]
Abstract
Selective apheresis procedures have been developed to target specific molecules, antibodies, or cellular elements in a variety of diseases. The advantage of the selective apheresis procedures over conventional therapeutic plasmapheresis is preservation of other essential plasma components such as albumin, immunoglobulins, and clotting factors. These procedures are more commonly employed in Europe and Japan, and few are available in the USA. Apheresis procedures discussed in this review include the various technologies available for low-density lipoprotein (LDL) apheresis, double filtration plasmapheresis (DFPP), cryofiltration, immunoadsorption procedures, adsorption resins that process plasma, extracorporeal photopheresis, and leukocyte apheresis.
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Affiliation(s)
- Amber P Sanchez
- Therapeutic Apheresis Program, Department of Medicine, Division of Nephrology and Hypertension, University of California San Diego Medical Center, San Diego, CA, USA.
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23
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Abstract
Low-density lipoprotein (LDL) apheresis describes a group of apheresis techniques that selectively remove apolipoprotein B-containing lipoproteins producing an acute reduction in LDL-cholesterol (LDL-C). Six devices are available for the removal of LDL-C while sparing other important plasma components. The LDL-apheresis (LDL-A) is not routinely used for the treatment of hypercholesterolemia, which usually responds to medical management, but is used to treat familial hypercholesterolemia, an inherited metabolic abnormality resulting in premature death due to progressive coronary artery disease, and to treat patients who fail medical management. The mechanism of action of the available LDL-A devices, reactions that can occur with these treatments, and the role of this specialized apheresis technique in the treatment of hypercholesterolemia are described.
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Affiliation(s)
- Jeffrey L Winters
- Department of Laboratory Medicine and Pathology, Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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24
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Winters JL. Lipid apheresis, indications, and principles. J Clin Apher 2011; 26:269-75. [DOI: 10.1002/jca.20299] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 07/05/2011] [Indexed: 12/18/2022]
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25
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Balogun RA, Ogunniyi A, Sanford K, Okafor C, Lobo PI, Siami G, Barcia J, Kaplan AA. Therapeutic apheresis in special populations. J Clin Apher 2010; 25:265-74. [DOI: 10.1002/jca.20250] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Huang CT, Li PN, Pai CY, Leu TS, Jen CP. Design and Simulation of a Microfluidic Blood-Plasma Separation Chip Using Microchannel Structures. SEP SCI TECHNOL 2010. [DOI: 10.1080/01496390903402125] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Ching-Te Huang
- a Department of Mechanical Engineering , National Chung Cheng University , Chia-Yi, Taiwan, R.O.C
| | - Po-Ni Li
- a Department of Mechanical Engineering , National Chung Cheng University , Chia-Yi, Taiwan, R.O.C
| | - Ching-Yi Pai
- b Department of Aeronautics and Astronautics , National Cheng Kung University , Tainan, Taiwan, R.O.C
| | - Tzong-Shyng Leu
- b Department of Aeronautics and Astronautics , National Cheng Kung University , Tainan, Taiwan, R.O.C
| | - Chun-Ping Jen
- a Department of Mechanical Engineering , National Chung Cheng University , Chia-Yi, Taiwan, R.O.C
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Crump KL, Seshadri R. Use of therapeutic plasmapheresis in a case of canine immune-mediated hemolytic anemia. J Vet Emerg Crit Care (San Antonio) 2009; 19:375-80. [PMID: 25164638 DOI: 10.1111/j.1476-4431.2009.00431.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the clinical application and potential utility of plasmapheresis in canine immune-mediated hemolytic anemia. CASE SUMMARY A 7-year-old spayed female Maltese diagnosed with immune-mediated hemolytic anemia was initially treated with prednisone, cyclosporine, and received multiple transfusions of packed RBC. Because of the progression of clinical signs despite traditional medical therapy, plasmapheresis was initiated. Plasma immunoglobulin G and immunoglobulin M levels were measured before, during, and after treatment to help determine if there had been a significant decrease in immunoglobulin levels with plasmapheresis. Plasmapheresis was successfully performed over a 2.5-hour period in this dog with minimal complications. Hypocalcemia was identified as a known complication of circuit anticoagulation, and was corrected through calcium supplementation. Post-plasmapheresis there was a decrease in immunoglobulin G and immunoglobulin M levels, and the patient showed clinical improvement. Following discharge the dog had no known complications of therapy, and had complete resolution of the anemia. NEW OR UNIQUE INFORMATION PROVIDED Plasmapheresis was performed successfully with minimal complications. Because transfusion requirements appeared to be reduced, and the procedure was well tolerated, there may be a place for this modality in severe cases to act as a bridge until medical therapy takes full effect. Because of the cost of performing this therapy, and the potential requirement for multiple treatments, it should be reserved for selected patients.
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Affiliation(s)
- Kathryn L Crump
- Advanced Critical Care and Internal Medicine, Tustin, CA 92780
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Liver support therapy with molecular adsorbents recirculating system in liver failure: a summary of 252 cases from 14 centers in China. Chin Med J (Engl) 2008. [DOI: 10.1097/00029330-200811010-00017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Gong D, Ren B, Ji D, Tao J, Xu B, Liu Z, Li Z. Selective albumin exchange: a novel and simple method to remove bilirubin. Int J Artif Organs 2008; 31:425-30. [PMID: 18609516 DOI: 10.1177/039139880803100508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Owing to its non-selectivity, plasma exchange has limited use in the treatment of patients with hepatic failure, although it is effective in removal of protein-bound toxins. This study reports a novel way to perform selective albumin exchange (SAE) by using a secondary plasma separator and aims to study its depurative capacity in the removal of bilirubin. METHOD In ex vivo experiments, the sieving coefficients (SCs) of plasma proteins for two secondary plasma separators, EC20W and EC30W (Asahi Medical, Tokyo, Japan), were measured. The EC20W membrane was chosen for use in clinical treatment because of its higher selectivity in separating albumin from plasma than the EC30W. The SCs of albumin, immunoglobumin G, A and M (IgG, IgA, IgM) for the EC20W were 0.3+/-0.021, 0.017+/-0.012, and 0, respectively. Five inpatients with plasma total bilirubin (TB) more than 200 micromol/L were enrolled in the present study and received a total of 10 SAE therapy sessions. Each session lasted 10 hours. SAE using the EC20W was conducted, making it similar to post-dilution continuous veno-venous hemofiltration (CVVH), with a filtrate rate of 2000 ml/h. Replacement fluid was composed by adding human albumin into conventional CVVH replacement fluid, with a final albumin concentration of 0.6%. During each treatment, the parameters of plasma and filtrate TB, direct bilirubin (DB), indirect bilirubin (IDB), and proteins were dynamically monitored. Hemostasis parameters were measured before and after sessions. RESULTS The reduction ratio of plasma TB, DB, and IDB after a single session was 29.1+/-3.0%, 31.3+/-4.5%, and 18.7+/-10.2%, respectively. The clearance of TB at initiation was 11.1+/-1.3 mL/min and declined to 4.4+/-0.5 ml/min at the end (p<0.01). This decline was accompanied by a reduction in albumin SC from 0.3+/-0.021 to 0.13+/-0.05. The molar ratio of bilirubin to albumin in filtrate was comparable to that in plasma. After a single treatment, plasma protein concentration including total protein, albumin, IgA and IgM remained unaffected, except for globulin and IgG, which were reduced by 11.5+/-7.8% and 11.1+/-2.3%, respectively. An improvement in hemostasis parameters, including plasma fibrinogen, prothrombase time and INR, was found after treatment. No obvious side effects were reported during any of the sessions. CONCLUSION Selective albumin exchange is a simple and effective method to remove bilirubin. However, further studies are required to verify its effects on clinical outcome.
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Affiliation(s)
- D Gong
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing - China.
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Yu X, Ma J, Tian J, Jiang S, Xu P, Han H, Wang L. A Controlled Study of Double Filtration Plasmapheresis in the Treatment of Active Rheumatoid Arthritis. J Clin Rheumatol 2007; 13:193-8. [PMID: 17762452 DOI: 10.1097/rhu.0b013e318124a483] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Double-filtration plasmapheresis with a plasma fractionator pore size of 20 nm should selectively remove large molecular weight substances like rheumatoid factor and IgM. This was proposed to be more likely to be helpful for rheumatoid arthritis than standard plasma exchange. OBJECTIVE To evaluate the efficacy of double-filtration plasmapheresis (DFPP) in the treatment of patients with active rheumatoid arthritis. METHODS Eighty-two patients were randomly assigned, 42 to the DFPP group and 40 to the no-DFPP group. All patients received sulfasalazine (0.75 g 3 times daily) plus methotrexate (10 mg orally once weekly). All patients had been on stable doses for more than 3 months. DFPP was performed once a week for 2 to 3 sessions. A total of 121 plasmapheresis procedures were performed in 42 patients. Control patients did not receive sham DFPP. The efficacy measures recorded 1 day after the final treatment and every month in follow-up for 4 to 22 months included the American College of Rheumatology (ACR) 20%, 50%, and 70% improvement criteria (ACR20, ACR50, and ACR70), the Health Assessment Questionnaire estimate of disability and the disease activity index. RESULTS Patients in the DFPP group had ACR20, ACR 50, and ACR70 improvements immediately after the last treatment of 100%, 92.9%, and 81.0%, when compared with the patients in no-DFPP group 17.5%, 0%, and 0% (P < 0.001). Significant change from baseline was observed in Health Assessment Questionnaire scores in the DFPP group, but not in the no-DFPP group (P < 0.001). The changes from baseline in the disease activity scores were significantly greater than in the no-DFPP group (P < 0.001). Improvements were maintained during follow-up of 7 to 22 months. CONCLUSION This open trial showed that DFPP therapy significantly altered the signs and symptoms of active rheumatoid arthritis. There were increases in physical function and improvement in quality of life. This is proposed as an approach that merits further investigation.
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Affiliation(s)
- Xiaoxia Yu
- Department of Rheumatology, Blood Purification Center of Cangzhou, Traditional Chinese Medicine-Western Medicine Hospital of Cangzhou of Hebei, Cangzhou, Hebei, People's Republic of China.
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Li LJ, Liu XL, Xu XW, Sheng GP, Chen Y, Chen YM, Huang JR, Yang Q. Comparison of Plasma Exchange With Different Membrane Pore Sizes in the Treatment of Severe Viral Hepatitis. Ther Apher Dial 2005; 9:396-401. [PMID: 16202014 DOI: 10.1111/j.1744-9987.2005.00277.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Plasma exchange has become an effective mode of blood purification in patients suffering from liver failure. To assist in patient recovery, we compared two plasma separators to identify a plasma separator with suitable pore sizes to remove toxic substances effectively, and retain important plasma components. The study focused on severe viral hepatitis patients. Of 206 rounds of plasma exchange, 137 were completed with the PS-06 plasma separator (membrane pore size=0.2 microm) and 69 with the EC-4A plasma separator (membrane pore size=0.03 microm). The efficacy of different plasma separators was compared using survival rate, changes in liver biochemistry, immunoglobulin, and complement parameters. The survival rate of patients treated with PS-06 was 43.3% (13 of 30 patients). For patients treated with EC-4A, two patients were bridged to liver transplantation successfully, and 57.9% (11 of 19 patients) survived. In both groups, the levels of total bilirubin, prothrombin time, and bile acid declined significantly. Compared to PS-06, EC-4A could retain significantly larger amounts of immunoglobulin and complements. Our study revealed that plasma exchange implementation with membrane pore size 0.03 microm could remove adequate bilirubin and bile acid, a class of toxins bound to plasma protein in severe viral hepatitis patients, and reduce the loss of essential plasma macromolecules.
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Affiliation(s)
- Lan Juan Li
- Department of Infectious Disease, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.
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Mischke R. Plasma transfusion and automated plasmapheresis - possibilities and limitations for veterinary medicine. Vet J 2005; 169:12-4. [PMID: 15683759 DOI: 10.1016/j.tvjl.2004.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Siami GA, Siami FS. The current status of therapeutic apheresis devices in the United States. Int J Artif Organs 2002; 25:499-502. [PMID: 12117288 DOI: 10.1177/039139880202500603] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Over the last 40 years, plasmapheresis technology and its indications for use have been continually evolving. With the growing incidence for autoimmune diseases, unsatisfactory therapeutic options, side effects of drug therapy, and economic relevance, apheresis clinicians have been leaning toward more selective plasmapheresis techniques through the use of plasma fractionators and immunoadsorption columns. Plasma fractionators are mostly used in Asia, and rarely utilized in the U.S. The majority of plasma filters approved by the Food and Drug Administration (FDA) are primary membrane plasma separators, which still require replacement fluid. The secondary plasma fractionators available in the U.S. are limited in used and mostly investigational. Immunoadsorption columns, mostly used in Europe, are gaining popularity in the U.S. Some FDA-approved immunoadsorption columns include the Prosorba protein-A silica column, Immunosorba tryptophan and phenylalanine columns, Immunosorba protein-A sepharose column, and Liposorber dextran sulfate column. In addition, the heparin-induce extracorporeal lipoprotein precipitation (HELP) system is also FDA-approved. However, there are other immunoadsorption technologies used in Europe, such as direct adsorption lipoprotein LDL-hemoperfusion, not yet available in the U.S. While each method of apheresis carries its own risks and benefits, it is the opinion of the authors that these additional apheresis techniques be available to U.S. researchers and clinicians as a therapeutic option. The authors believe that the U.S. need to aggressively investigate more specific plasmapheresis modalities and establish appropriate dialogue with regulatory and reimbursement officials for FDA-approval of these devices.
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Affiliation(s)
- G A Siami
- Vanderbilt University, Department of Medicine, Nashville, Tennessee 37212-2637, USA.
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