Therapeutic plasma exchange in the intensive care setting

Plasmapheresis as an Alternative Treatment of Hypertriglyceridemia-Induced Pancreatitis: A Case Report

Hypertriglyceridemia-induced pancreatitis is a relatively common form of acute pancreatitis that may represent up to 10% of all etiologies of this condition. Due to its specific pathogenic mechanisms related to high serum triglyceride levels, different treatment options have been proposed, including insulin perfusion, heparin perfusion, and plasmapheresis. Although the superiority of plasmapheresis in this clinical setting has not been demonstrated in randomized clinical trials, many centers have reported its effectiveness and considered this as a possible alternative according to the current guidelines. We report a case of a young patient diagnosed with hypertriglyceridemia-induced pancreatitis that was successfully treated with plasmapheresis. Since complications associated with plasmapheresis are rare and other therapeutic options may not be so effective or safe, we believe that this should be a valid alternative treatment that may be offered to these patients. More studies are still needed to further evaluate its effectiveness and to elucidate if there is a subset of patients in whom treatment with plasmapheresis may be more beneficial.

Membrane-based therapeutic plasma exchange in tertiary care ICU: demographic characteristics and predictors of complications

Introduction: Membrane-based therapeutic plasma exchange (mTPE) has been used to treat various diseases in the intensive care unit (ICU) setting. However, there is a lack of clinical data regarding the practice of mTPE from Australian ICUs. Objectives: To determine factors contributing to complications in patients undergoing mTPE in the ICU. Methods: Prospectively collected data for mTPE procedures performed at the ICU of Flinders Medical Centre between April 2014 and December 2020 were analysed. Results: During the study period, 674 mTPE treatments were performed in 140 patients (71 females, 50.7%). Haematological disease (30.4%) was the most common indication for mTPE treatment. Citrate was the most common anticoagulation for mTPE (86.1%), while albumin (42.3%) was the most common replacement fluid. Circuit complications occurred in 18.6% of the total mTPE treatments. On logistical regression analysis, treatment ionised calcium level (odds ratio [OR], 42.2; 95% CI, 1.8-975.0; P = 0.02), male sex (OR, 2.04; 95% CI, 1.04-4; P = 0.04), duration of mTPE treatment (OR, 1.02; 95% CI, 1.01-1.02; P < 0.001) and diagnostic categories (P = 0.03) were predictors of circuit complications. During mTPE treatment, 87.2% of patients did not experience any complications. On logistical regression analysis, replacement fluid type (P = 0.03), lower initial blood flow (OR, 0.9; 95% CI, 0.9-1.0; P = 0.04) and higher exchange volume (OR, 8.9; 95% CI, 1.6-48.7; P = 0.01) were predictors of patient complications. Conclusion: During mTPE, pre-treatment ionised calcium level, male sex, duration of mTPE and diagnostic categories were predictors of circuit complications, while replacement fluid type, initial blood flow and higher exchange volume were predictors of patient complications.

Extracorporeal blood purification in acutely intoxicated veterinary patients: A multicenter retrospective study (2011-2018): 54 cases

OBJECTIVE

To investigate the clinical outcome and complications associated with extracorporeal blood purification (EBP) using either hemodialysis (HD), hemodialysis and hemoperfusion (HD + HP), or therapeutic plasma exchange (TPE) for the management of acute toxin ingestion in small animals.

DESIGN

Retrospective, multicenter study from January 2011 to July 2018.

SETTING

One university teaching hospital and one private specialty hospital.

ANIMALS

Fifty-one dogs and 3 cats with a history of acute toxin exposure that could lead to severe morbidity and mortality, managed with different EBP techniques.

MAIN RESULTS

Nonsteroidal anti-inflammatory drugs (38/54, 52%), baclofen (8/54, 15%), and ethylene glycol (7/54, 13%) were the most common toxicities treated with EBP. Membrane-based TPE was used most commonly (22/54, 40.7%), followed by HD (17/54, 31.5%) and then HD + HP (15/54, 27.8%). There was an 83.3% (45/54) overall survival, with 88.9% (8/9) of nonsurvivors having clinical signs prior to therapy. One third (18/54) of the patients never developed clinical signs of toxicity. Treatment complications occurred in 44.4% (24/54) of the animals, although only 18.5% (10/54) of these complications, such as mild hypotension, thrombocytopenia secondary to the HP cartridge, facial swelling after plasma transfusion for TPE, bleeding from catheter size secondary to heparinization, or clotting of the system, could be attributed to the EBP treatment. None of the nonsurvivors died because of EBP complications.

CONCLUSIONS

Early initiation of EBP therapy might be considered as an alternative route of decontamination in severe acute toxicities with high potential for significant morbidity and mortality. The survival rate in small animals undergoing EBP is high despite exposure to potential lethal doses of toxins, and survival appears to be more likely if clinical signs of toxicity are not present at the time of EBP. Continued research is warranted with randomized controlled clinical trials to further evaluate the clinical efficacy and benefit of EBP.

Ferroptosis and Necroptosis in the Kidney

In the last decade, the role of apoptosis in the pathophysiology of acute kidney injury (AKI) and AKI to chronic kidney disease (CKD) progression has been revisited as our understanding of ferroptosis and necroptosis has emerged. A growing body of evidence, reviewed here, ascribes a central pathophysiological role for ferroptosis and necroptosis to AKI, nephron loss, and acute tubular necrosis. We will introduce concepts to the non-cell-autonomous manner of kidney tubular injury during ferroptosis, a phenomenon that we refer to as a "wave of death." We hypothesize that necroptosis might initiate cell death propagation through ferroptosis. The remaining necrotic debris requires effective removal processes to prevent a secondary inflammatory response, referred to as necroinflammation. Open questions include the differences in the immunogenicity of ferroptosis and necroptosis, and the specificity of necrostatins and ferrostatins to therapeutically target these processes to prevent AKI-to-CKD progression and end-stage renal disease.

Therapeutic Plasma Exchange in the Critically Ill Patient: Technology and Indications

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.

Outcomes of Immune Thrombotic Thrombocytopenic Purpura (iTTP) With Upfront Cyclophosphamide vs. Rituximab

Background: Immune thrombotic thrombocytopenic purpura (iTTP) is a rare, life-threatening disorder managed with plasma exchange (PLEX) and steroids. Addition of rituximab (RTX) to initial disease treatment has been shown to lower future relapse rates. Information as to whether upfront cyclophosphamide (CTX) treatment is helpful in reducing relapse is not known.

Methods: In a retrospective cohort study, we identified all patients at our institution diagnosed with iTTP between 2010 and 2019. We analyzed outcomes of cumulative incidence of relapse (CIR) and duration of remission.

Results: Thirty Nine patients were studied. Group A (n = 10) included patients who received upfront PLEX and steroids alone, and Group B (n = 28) included those who received either upfront RTX (n = 23) or CTX (n = 5) in addition to PLEX and steroids. The 2-year CIR was 50% in Group A and 27.7% in Group B, with a median duration of remission of 43.6 months vs. 108.3 months, respectively (p = 0.04). Group A was associated with a HR=8.7 (95% CI: 1.27, 59.45), p = 0.027 for duration of remission. There was no significant difference between CTX and RTX in both outcomes of CIR and duration of remission. We observed a potential impact on remission duration based on the presenting absolute neutrophil count (HR = 0.74, 95% CI: 0.58, 0.96) and serum creatinine (HR = 1.42, 95% CI: 1.03, 1.94).

Conclusion: There was no significant difference in iTTP relapse outcomes between upfront RTX and CTX. Absolute neutrophil count and serum creatinine may have a role in predicting relapse. Larger, prospective studies are needed to evaluate these findings.

Drug Dosing in Patients Undergoing Therapeutic Plasma Exchange

Therapeutic plasma exchange (TPE) is an extracorporeal process in which a large volume of whole blood is taken from the patient's vein. Plasma is then separated from the other cellular components of the blood and discarded while the remaining blood components may then be returned to the patient. Replacement fluids such as albumin or fresh-frozen plasma may or may not be used. TPE has been used clinically for the removal of pathologic targets in the plasma in a variety of conditions, such as pathogenic antibodies in autoimmune disorders. TPE is becoming more common in the neurointensive care space as autoimmunity has been shown to play an etiological role in many acute neurological disorders. It is important to note that not only does TPE removes pathologic elements from the plasma, but may also remove drugs, which may be an intended or unintended consequence. The objective of the current review is to provide an up-to-date summary of the available evidence pertaining to drug removal via TPE and provide relevant clinical suggestions where applicable. This review also aims to provide an easy-to-follow clinical tool in order to determine the possibility of a drug removal via TPE given the procedure-specific and pharmacokinetic drug properties.

Plasma Filtration Versus Centrifugation in Pediatric Therapeutic Plasma Exchange: Should the Diagnosis Define the Method?†

Therapeutic plasma exchange (TPE) is used for a variety of illnesses in critically ill pediatric patients. Although both centrifugation and filtration are known to be effective methods, to our knowledge, clinical results for TPE by these methods are not compared in pediatric patient populations. One hundred patients who had TPE for a variety of diagnoses were included in the study. In 55 patients plasma exchange was implemented by centrifugation and in 45, by filtration. These two groups were further divided into subgroups according to admittance diagnoses. The demographic information, admittance Pediatric Risk of Mortality scores, Pediatric Logistic Organ Dysfunction (PELOD) scores before beginning of therapy and PELOD at the end of therapy, durations of ventilatory support, pediatric intensive care unit and hospital stay, and outcomes were compared. Although the survival was significantly better in filtration group, it included more patients with neurologic diagnoses. Filtration group standard mortality rate was 0.6. In both groups, the PELOD scores after the termination of TPE were significantly decreased compared to that before beginning of TPE. Within thrombotic microangiopathy and hemophagocytic lymphohistiocytosis subgroups, median PELOD scores before treatment were higher in centrifugation patients but survival was similar with both methods. Both methods of TPE are alike in decreasing PELOD scores. In the filtration group, survival benefit of TPE is evident. In thrombotic microangiopathy patients, despite higher PELOD scores in the centrifugation group, survival is similar for both methods. These findings should be retested in randomized studies and the underlying physiology awaits to be uncovered.

Bad weed: synthetic cannabinoid–associated coagulopathy

Recent multistate outbreaks of coagulopathy caused by brodifacoum-tainted synthetic cannabinoids or “fake weed” highlight the public health impact of long-acting anticoagulant rodenticides (LAARs). Patients presenting with this syndrome have had recent exposure to synthetic cannabinoids, evidence of isolated vitamin K antagonism with or without bleeding, and detectable levels of brodifacoum and other LAARs in circulation. This article will provide information on synthetic cannabinoids, LAARs, and coagulopathic manifestations arising from use of adulterated synthetic cannabinoids and their management.

Treatment of Polypharmacy Overdose with Multimodality Extracorporeal Life Support

A 45-year-old woman presented to the emergency department of a tertiary referral hospital after taking an overdose of verapamil, doxepin, quetiapine, diazepam, temazepam, and clonazepam. She rapidly developed shock refractory to pharmacological support and was placed on percutaneous venoarterial extracorporeal membrane oxygenation (ECMO). She had a severe metabolic acidosis from a combination of shock and drug intoxication that improved with continuous venovenous haemodialysis. Forty-eight hours after presentation, while still on ECMO, the patient had complete cardiac standstill for three and a half hours, attributable to slow-release verapamil, that resolved after the commencement of plasmapheresis. The role of plasmapheresis in verapamil overdose requires further study.

The clinical relevance of necroinflammation-highlighting the importance of acute kidney injury and the adrenal glands

Necroinflammation is defined as the inflammatory response to necrotic cell death. Different necrotic cell death pathways exhibit different immune reponses, despite a comparable level of intracellular content release (referred to as damage associated molecular patterns or DAMPs). In addition to DAMP release, which is inevitably associated with necrotic cell death, the active production of pro/anti-inflammatory cytokines characterizes certain necrotic pathways. Necroptosis, ferroptosis and pyroptosis, therefore, are immunogenic to a different extent. In this review, we discuss the clinical relevance of necroinflammation highlighting potential human serum markers. We focus on the role of the adrenal glands and the lungs as central organs affected by systemic and/or local DAMP release and underline their role in intensive care medicine. In addition, data from models of acute kidney injury (AKI) and kidney transplantation have significantly shaped the field of necroinflammation and may be helpful for the understanding of the potential role of dialysis and plasma exchange to treat ongoing necroinflammation upon intensive care unit (ICU) conditions. In conclusion, we are only beginning to understand the importance of necroinflammation in diseases and transplantation, including xenotransplantation. However, given the existing efforts to develop inhibitors of necrotic cell death (ferrostatins, necrostatins, etc), we consider it likely that interference with necroinflammation reaches clinical routine in the near future.

Therapeutic Plasma Exchange and Its Impact on Drug Levels: An ACLPS Critical Review

OBJECTIVES

To examine and summarize the current literature on the effects of therapeutic plasma exchange on medication levels.

METHODS

Literature review was performed via searches of the Cochrane Database and PubMed-MEDLINE (1996 to August 2016) looking for all case reports, case series, and human randomized controlled trials involving therapeutic plasma exchange (TPE)-associated drug removal.

RESULTS

Approximately 60 peer-reviewed articles were identified with the majority being case reports; no randomized controlled trials were identified. These reports and the authors' own experiences were used to derive practical guidance regarding the effect of TPE on circulating drug levels.

CONCLUSIONS

There were several limitations with existing studies, many of which relate to procedural and/or clinical properties of patients undergoing TPE. As such, additional studies are needed before definitive guidelines can be established. There is clear need for development of consensus and additional investigations in this domain.

Therapeutic plasma exchange: a second-line treatment for brodifacoum poisoning following an anaphylactoid reaction to vitamin K

Vitamin K1 is the first‐line therapy to brodifacoum poisoning. Anaphylactoid reactions may occur anytime during intravenous administration of vitamin K1 injection. Vitamin K1 must be ceased when anaphylactoid reactions emerge, and therapeutic plasma exchange could be a second‐line option.

Extracorporeal Life Support in Severe Propranolol and Verapamil Intoxication

Combined poisoning with calcium-channel blockers and β-blockers is usually associated with severe heart failure. This report shows the effectiveness of emergency extracorporeal life support in treating life-threatening simultaneous propranolol and verapamil intoxication. A 15-year-old girl presented in cardiogenic shock after alcohol consumption and a propranolol and verapamil overdose; plasma concentrations: propranolol, 0.53 m/mL; verapamil, 1.06 mg/mL. She was successfully resuscitated with extracorporeal life support. Therapeutic plasma exchange was initiated. Extracorporeal support was discontinued 70 hours later. The patient made a full recovery. Simultaneous verapamil and propranolol overdoses can cause severe hemodynamic compromise and arrest of electrical and mechanical function of the heart. Emergency extracorporeal life support can successfully maintain vital organ blood flow and allows time for drug metabolism, redistribution, and removal. Therapeutic plasma exchange may reduce the time of emergency extracorporeal life support. Emergency extracorporeal life support should be considered early in cases of near-fatal intoxications with cardiodepressive drugs.

Utilization of plasmapheresis for organophosphate intoxication: A case report

Organophosphate (OP) compounds are extremely toxic chemicals that may be absorbed via skin, conjunctiva, gastrointestinal and respiratory systems. Treatment of OP poisoning is a critical and aggressive process which includes decontamination, antidote administration (atropin and oximes), mechanical ventilation support and extracorporeal elimination procedures if needed. Here we present a young female patient who was unintentionally poisoned by an OP (trichlorfon) after using it to moisture her skin. The importance of this patient is the dermal disease that makes her unprotective to dermal exposure of chemicals and application of plasmapheresis to treat her poisoning.

Plasma exchange for kidney disease: what is the best evidence?

Therapeutic plasma exchange (TPE) has been used as adjunctive therapy for various kidney diseases dating back to the 1970s. In many cases, support for TPE was on mechanistic grounds given the potential to remove unwanted large molecular-weight substances such as autoantibodies, immune complexes, myeloma light chains, and cryoglobulins. More recently, growing evidence from randomized controlled trials, meta-analyses, and prospective studies has provided insights into more rational use of this therapy. This report describes the role of TPE for the 6 most common kidney indications in the 2013 Canadian Apheresis Group (CAG) registry and the evidence that underpins current recommendations and practice. These kidney indications include thrombotic microangiopathy, antiglomerular basement membrane disease, anti-neutrophil cytoplasmic antibody-associated vasculitis, cryoglobulinemia, recurrence of focal and segmental glomerulosclerosis in the kidney allograft, and kidney transplantation.

Medications in patients treated with therapeutic plasma exchange: prescription dosage, timing, and drug overdose

Therapeutic plasma exchange (TPE) is an extracorporeal process commonly used in clinical medicine for the treatment of a variety of neurological, renal, hematological, dermatological, and other diseases. Inherent to the procedure, patients' plasma removal may lead to the extraction of drugs they are concurrently receiving. This review discusses the published literature assessing TPE's influence on different drug classes' disposition and, when applicable, sets forth management recommendations in cases where the drugs are used at the usual doses and in cases of drug overdose.

The challenge of pain management in patients with myasthenia gravis

Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction. The complexity of the disease and its treatments make MG patients particularly susceptible to adverse effects of drugs. MG is not a painful condition; however, as pain management armamentarium includes drugs from diverse pharmacological groups and with potential for drug-drug interactions, managing pain in patients with MG can be challenging. The underlying disease and the concomitant medications of each patient must be considered and the analgesic treatment individualized. This review presents an update on the various aspects of pain pharmacotherapy in patients with MG, focusing primarily on medications used to treat chronic pain. Drugs discussed are opioids, nonsteroidal anti-inflammatory drugs, antidepressants, anticonvulsants, muscle relaxants, benzodiazepines, intravenous magnesium, and local anesthetics. Drug interactions with agents used for MG treatment (acethylcholinesterase inhibitors, corticosteroids, immunosuppressants) and plasmapheresis are discussed. The clinical usefulness and limitations of each of the drug classes and agents are described.

Comparison of citrate anticoagulation during plasma exchange with different replacement solutions

The aim of our retrospective study was to compare the application of regional citrate anticoagulation and citrate-related side-effects in plasma exchange (PE) with different replacement solutions. We included 35 patients treated with PE with regional citrate anticoagulation and divided them into three groups according to the replacement solution used: human albumin (HA) group (40 PE treatments), fresh frozen plasma (FFP) group (86 PE treatments), or a combination of the two (63 PE treatments). The citrate anticoagulation parameters, ionized calcium and metabolic consequences of citrate were compared. The blood flow and citrate infusion rates were similar in all groups. To maintain comparable values of ionized calcium during PE, significantly more calcium was replaced in the combination group (7.6 +/- 1.3 vs. 6.2 +/- 2.7 mL/h, P < 0.001) and even more in the FFP group (10.8 +/- 1.7 vs. 6.2 +/- 2.7 mL/h, P < 0.001) as compared to the HA group. The pH increased significantly and comparably in all groups, but the increase in bicarbonate was significantly higher in the FFP group (4.4 +/- 3.0 vs. 2.6 +/- 2.1 mmol/L, P = 0.01). A short, heparin-free hemodialysis session was performed after the PE treatment, because of significant metabolic alkalosis (mainly with pH > or = 7.5), significantly more often in the FFP group (14/86 PE, P < 0.01) as compared to the HA group (0/40), and only rarely in the combination group (2/63). To conclude, when FFP is used as a replacement solution during PE with citrate anticoagulation, significantly more calcium needs to be replaced and the increase in bicarbonate is greater during PE. The additional citrate contained in FFP, combined with frequent PE treatments, often causes significant metabolic alkalosis, which can be efficiently corrected with a short heparin-free hemodialysis.

A case report of efficiency of double filtration plasmapheresis in treatment of Goodpasture's syndrome

Goodpasture's syndrome is characterized by pulmonary hemorrhage, rapid progressive glomerulonephritis and the presence of anti-glomerular basement membrane (anti-GBM) antibodies. Here, we report a case of Goodpasture's syndrome that we treated with double filtration plasmapheresis (DFPP) combined with immunosuppression therapy. The patient was a 32-year-old man with the main complaints of low-grade fever, general fatigue and dyspnea. The clinical diagnosis was renal-pulmonary syndrome based on pulmonary hemorrhage on chest X-ray, rapid progressive renal insufficiency, and elevated C-reactive protein (CRP). Goodpasture's syndrome was diagnosed because the patient was negative for MPO-ANCA and PR3-ANCA, and positive for anti-GBM antibodies. Renal biopsy showed crescentic glomerulonephritis. Hemodialysis, immunosuppression therapy (methylprednisolone and cyclophosphamide) and DFPP were performed. Anti-GBM antibodies were followed pre- and post-DFPP, and removal efficiency, cost performance and complications were evaluated. The antibody levels were 121 and 84 EU/mL before and after the first DFPP procedure, respectively, giving a removal efficiency of 24%. Subsequently, the removal efficiencies were 52%, 55% and 60% after the second, third and fourth DFPP procedures. For comparison, the immunoglobulin G (IgG) removal efficiencies were 53%, 57%, 60% and 55% after the four respective DFPP procedures; therefore, the removal efficiencies were similar for anti-GBM antibodies and IgG in all except the first DFPP procedure. The serum anti-GBM antibody and IgG concentrations decreased from pre- to post-DFPP, indicating that DFPP may be an effective therapeutic approach in Goodpasture's syndrome.

Drug removal by plasmapheresis: an evidence-based review

Contrary to the literature about drug removal during hemodialysis, data regarding drug removal during plasmapheresis are sparse. Over the last 40 years, approximately 70 publications-mostly case reports of overdoses-have described the effects of plasmapheresis on pharmaceutical agents. Important issues are drug extraction during plasma exchange with chemotherapy, as well as drug classes such as antiinfectives, anticoagulants, antiepileptics, cardiovascular agents, and immunosuppressants. Other considerations are the merits and pitfalls of the different methods used in published reports and recommendations for future pharmacokinetic studies in this field.

Successful treatment of propafenone, digoxin and warfarin overdosage with plasma exchange therapy and rifampicin

We report here the successful treatment of a 16-year-old female who ingested 20 tablets of digoxin each containing 0.25 mg (total dose ingested equivalent to 0.1 mg/kg), 32 tablets of warfarin each containing 5mg (equivalent to 3.2 mg/kg), and approximately 15 tablets of propafenone each containing 300 mg (equivalent to 90 mg/kg). The patient developed hypotension and sinus bradycardia necessitating external cardiac pacing 17 hours after drug ingestion. In addition to gastric lavage, activated charcoal, blood alkalinisation, administration of vitamin K and temporary cardiac pacing, the authors performed plasma exchange for drug removal and administered rifampicin in order to increase the metabolism of digoxin, propafenone and warfarin. The patient was discharged without any sequelae. Plasma exchange may be lifesaving in drug ingestions where there is a low volume of distribution and high plasma protein binding. Rifampicin, an inducer of cytochrome p450, may be used in intoxications for elimination of drugs with inactive metabolites.

A Case Report of Pulmonary-Renal Syndrome Treated With Continuous Hemodiafiltration and Hemodialysis

This case describes a 40-year-old man complaining of general malaise, dyspnea with hemoptysis and anuria. Laboratory data indicated renal failure and the presence of systemic inflammation. His chest radiograph and computed tomography showed bilateral diffuse interstitial alveolar infiltration. These findings indicated acute deterioration of chronic renal dysfunction complicated by interstitial pneumonitis. He initially received daily conventional hemodialysis (HD), an antibiotic and oxygen therapy. However, his renal and pulmonary function continued to deteriorate. Antineutrophil cytoplasm antibodies against myeloperoxidase (MPO-ANCA) and antibodies against proteinase 3 (PR3-ANCA) were negative. We suspected that his pulmonary-renal syndrome was caused by ANCA-negative vasculitis. We applied mechanical ventilation, pulsed methylprednisolone therapy and continuous hemodiafiltration (CHDF) combined with HD. PaO(2)/FiO(2) ratio and mean pulmonary arterial pressure gradually improved after initiation of CHDF. He was finally separated from mechanical ventilation after 44 days in the hospital. He is currently alive with the support of conventional HD.

Vascular access for apheresis in intensive care patients

In the intensive care unit, apheresis therapy (including plasma exchange, selective immunoadsorption and -affinity and detoxification by hemoperfusion) is limited to certain disease entities. Temporary insertion of large-bore central venous catheters is necessary for efficient performance of apheresis therapy. The choice of the optimal catheter insertion site (femoral, subclavian or internal jugular vein route) depends on the individual situation, the experience of the operator and the anticipated treatment period. Morbidity and mortality of the patients concerned can be substantially increased by insertion and use of central venous catheters. Early and delayed complications are briefly discussed. Appropriate selection of the catheter insertion site, the catheter type, strictly aseptic insertion procedures and optimal care of catheter and insertion site are essential to avoid complications.

Plasma exchange for hypertriglyceridemic acute necrotizing pancreatitis: report of two cases

We report two cases of hypertriglyceridemic necrotizing pancreatitis treated by plasma exchange (PE). The outcome of each case was quite different according to the timing of PE. A 36 year old man presented with abdominal pain, and a diagnosis of severe acute pancreatitis was made. His serum triglyceride (TG) level was 6,460 mg/dl. He did not undergo PE at first, however, his condition never improved and PE was performed 20 days after the onset of his illness. Finally, he died of multiple organ failure and sepsis. In contrast, a 52 year old man with acute necrotizing pancreatitis was referred to our department. He received PE quickly after hospital admission. His serum TG level, which was 3,540 mg/dl at hospital admission, dramatically returned to normal limits, and he was discharged from the hospital 62 days after admission. The prognosis of severe necrotizing pancreatitis due to hypertriglyceridemia is extremely poor. PE should be applied for the treatment of hypertriglyceridemic necrotizing pancreatitis immediately after its onset.