Plasmapheresis in the University of Malaya Medical Centre, Malaysia

The establishment of in-house neurology driven therapeutic plasma exchange infrastructure in a resource-limited public hospital in Malaysia: Adopting and integrating evidenced-based health care technology through time

There has been an increase in the use of therapeutic plasma exchange (TPE) in immune-mediated neurological disorders in recent years. However, accessibility and availability of TPE remains low and costly, especially for a country with limited healthcare funding like Malaysia. With expanding clinical indications in neurological disorders, and increasingly expensive conventional immunomodulatory treatment such as intravenous immunoglobulin and monoclonal antibodies, TPE remains an effective part of first or second-line treatment. In this article, we detailed the historical aspects of the use of TPE in neurological disorders in Malaysia over the last four decades and discussed the challenges behind the establishment of the first in-house neurology-driven TPE service in the country. Local TPE database from a national neurology centre in Kuala Lumpur over the past 20 years was analyzed. We observed a remarkable three folds increase in the use of TPE at our center over the past 10 years (total 131 TPE treatments) compared to a decade prior, with expanding clinical indications predominantly for central nervous system demyelinating disorders. Besides using membrane filtration method, centrifugal technique was adopted, providing new opportunities for other clinical beneficiaries such as a neurologist driven "in-house TPE unit". However, there were real world challenges, especially having to provide services with limited funding, human resources, and space. In addition, much has to be done to improve accessibility, availability, and sustainability of TPE services at our center and nationwide. Nevertheless, even with limited resources and support, it is possible with concerted efforts to work within the confines of these limitations to establish a safe, successful, and sustainable TPE service.

Second regional plasmapheresis conference and workshop for Southeast Asia (SEA) on the immunomodulatory role of plasma exchange in central and peripheral nervous system disorders, Kuala Lumpur, Malaysia, 9th December 2017

In December 2017, 79 delegates attended the 2nd regional plasmapheresis conference and workshop for Southeast Asia (SEA) on the immunomodulatory role of plasma exchange in central and peripheral nervous system disorders in Kuala Lumpur, Malaysia. This meeting featured 6 plenary lectures, interactive sessions dedicated for experience sharing, case presentations, and a practical session for paramedics. Clinical experts and researchers from 7 SEA countries and India shared experience and challenges in treating autoimmune neurological disorders. While the spectrum of diseases and neurology practice remained largely similar, there was great disparities in accessibility of therapeutic plasma exchange (TPE) within SEA countries and between urban or rural settings. Costs, human resources, and healthcare policies are common challenges in providing sustainable TPE services. Novel techniques and innovative ideas in performing TPE were explored. A working consortium comprising of key opinion leaders was proposed to improve standards of TPE and enhance future research.

Therapeutic plasma exchange: Experience in a third level hospital, 2013-2016, Lima (Peru)

BACKGROUND

Therapeutic plasma exchange (TPE) is an extracorporeal procedure which consists of removing the patient's plasma and replacing it with an appropriate replacement fluid. Plasma and blood cells are separated by a centrifugation process. Our department has used TPE for several years, and in 2013 we introduced an institutional apheresis protocol. The main objective of this report is to describe the TPE procedures performed between 2013 and 2016 in the Peruvian population.

METHODS

We analyzed the technical and clinical aspects of 864 centrifugal TPE procedures as well as the associated complications. We evaluated 230 patients treated in our institution.

RESULTS

The therapeutic indications included 16 different diseases: 89.5% (N = 206/230) neurological, 7.3% (N = 17/230) hematological, 1.7% (N = 4/230) rheumatologic, 0.8% (N = 2/230) dermatological and 0.4% (N = 1/230) nephrological. 70.4% (N = 142/230) of patients were diagnosed with Guillain-Barré syndrome. Albumin 5% solution was the most frequent replacement solution, used in 65.8% (N = 569/864) of the procedures. The mean plasma volume (PV) replaced was 2451.73 ml, corresponding to 1.0 PV in all procedures. Complications occurred in 10.9% (N = 95/864) of the sessions. Allergic reactions were the most common events and cardiopulmonary arrests were recorded in two patients.

CONCLUSION

This is the first report of TPE performed in the Peruvian population. The use of an institutional apheresis protocol was beneficial to improve registries in our service and our professional health attention. This study reports a low rate of complications, suggesting that TPE is safe. There is a need to create a multicenter Peruvian apheresis registry to assess the benefits and risks of TPE in Peru.

Mean arterial pressure and systolic blood pressure for detection of hypotension during hemapheresis: implications for patients with baseline hypertension

Mean arterial pressure (MAP) has been characterized as a more sensitive and physiologically appropriate hemodynamic parameter in the detection of hemapheresis-related hypotension, resulting in a much closer correlation with the presence of symptomatic hypotension. Patients were enrolled over a 12-month period and data collected on any previous diagnosis of hypertension, antihypertensive therapy used, indication for apheresis, age decile, and gender. Baseline vital signs, any hypotensive signs or symptoms observed, and the patient's vital signs at the time of any hypotensive episode were recorded. Patients were assigned to a subgroup, sensitivity and specificity analysis performed, positive likelihood ratios calculated, receiver operating characteristic curves constructed, and ideal cutoff values identified. The incidence of hypotension among our study population was found to be 6.8%. Over all procedures, systolic blood pressure (SBP) was determined to be a "poor" test for detecting hypotension, while MAP demonstrated a "fair" capacity. A downward normalization was evident in the ideal cutoff value based upon a patient's hypertensive history. The currently accepted SBP less than 80 mmHg cutoff failed to detect hypotensive episodes among baseline hypertensive patients, raising questions about its sensitivity. Based upon physiologic principles and study findings, a MAP-based criterion is preferable in the diagnosis of hypotension during hemapheresis.