Experience with Tandem Pre-Dilution Online Hemodiafiltration and Centrifugal Plasma Exchange in Pretransplant Desensitization for Abo-Incompatible Kidney Transplantation: A Case Report

BACKGROUND

In the use of therapeutic plasma exchange (TPE) as antibody removal therapy for ABO-incompatible (ABOi) kidney transplantation, it is technically possible to perform online hemodiafiltration (OHDF) and TPE simultaneously for patients who are receiving OHDF. In this study, we report tandem therapy of pre-dilution OHDF and centrifugal plasma exchange (cTPE), instead of membrane plasma exchange, which is the mainstay of TPE in Japan.

METHODS

A total of 14 sessions of tandem cTPE and pre-dilution OHDF were performed as preoperative antibody removal therapy for 6 ABOi kidney transplant recipients. cTPE intra-circuit pressure, decreased antibody titer, and adverse events were evaluated. The study was carried out following the ethical standards of the Declaration of Helsinki and Istanbul. Donors were not prisoners or individuals who were coerced or paid.

RESULTS

The tandem therapy was completed safely in 12 of the 14 sessions, with no problems such as pressure upper and lower limit alarms or circuit coagulation. In 2 sessions, the tandem therapy had to be interrupted due to coagulation on the dialysis circuit side. Antibody titers were reduced by a median of 3-fold for both IgG and IgM. There was no acute antibody-associated rejection.

CONCLUSIONS

In preoperative apheresis therapy for ABOi kidney transplantation, tandem therapy of pre-dilution OHDF and cTPE may be a useful treatment option that can be performed safely and results in sufficient reduction of antibody levels.

Therapeutic plasma exchange in the intensive care unit: Rationale, special considerations, and techniques for combined circuits

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.

Tandem plasmapheresis and continuous kidney replacement treatment in pediatric patients

BACKGROUND

The objectives of the study are to describe tandem therapeutic plasma exchange (TPE) and continuous kidney replacement therapy (CKRT) patients' outcomes in a large institution.

METHODS

We reviewed pediatric patients receiving tandem TPE and CKRT from 2013 to 2016. Over the study period, 63 discrete patients received tandem TPE and CKRT for a total of 378 TPE procedures on 1676 days on CKRT.

RESULTS

Patient age ranged from newborn to 19 years old with weights ranging from 2.31 to 112.3 kg (17 patients were < 10 kg and less than 1 year old). All procedures were completed in intensive care units (ICU) as CKRT can only be done in this environment. All treatments completed successfully; majority of patients (90%) developed hypocalcemia though none were symptomatic. Case mortality rate was 40%. Disease severity scores at ICU admission were higher and time to TPE and CKRT start was longer in the deceased group.

CONCLUSIONS

As a conclusion, though complications including hypocalcemia are common with tandem TPE and CKRT in pediatrics, patients remained asymptomatic. Such treatments have to be carefully planned with interdisciplinary teams to address indications, technicalities, and complications.

Description of parallel and sequential configurations for concurrent therapeutic plasma exchange and continuous kidney replacement therapy in adults

Therapeutic plasma exchange (TPE) and continuous kidney replacement therapy (CKRT) are extracorporeal therapeutic procedures often implemented in management of patients. Critically ill patients may be afflicted with disease processes that require both TPE and CKRT. Performing TPE discontinuous with CKRT is technically easier, however, it disrupts CKRT and may compromise with CKRT efficiency or hemofilter life. Concurrent TPE with CKRT offers several advantages including simultaneous control of disease process and correction of electrolyte, fluid, and acid-base disturbances that may accompany TPE. Additionally, TPE may be performed by either centrifugation method or membrane plasma separation method. The technical specifications of these methods may influence the methodology of concurrent connections. This report describes and reviews two different approaches to circuit arrangements when establishing concurrent TPE and CKRT.

In tandem extracorporeal therapies during hemodialysis in pediatric patients

We describe the successful treatment of a pediatric transplant patient with simultaneous intermittent hemodialysis and therapeutic plasma exchange (TPE). The patient presented with kidney graft failure. He had life threatening electrolyte disturbances and fluid overload due to antibody-mediated rejection. Therefore, he was in need of both emergent kidney replacement therapy and TPE. Both extracorporeal circuits were set up, established, and maintained safely and effectively without difficulty or alarms. Running intermittent hemodialysis and TPE simultaneously significantly reduced therapy time, allowed both needed therapies priority, and provided a superior pediatric patient experience in an acute situation.

Citrate Anticoagulation in Tandem Membrane Plasma-Exchange or Immunoadsorption and Hemodialysis in Patients With Immunological Diseases and Dialysis-Dependence

In 1996 we performed tandem membrane plasma exchange-hemodialysis in a 3-year-old girl and tandem immunoadsorption-hemodialysis with citrate as the only anticoagulant in a patient with Goodpasture's syndrome. In the present study, we evaluated the feasibility, efficacy and safety of 24 tandem plasma exchange/immunoadsorption hemodialysis procedures in four different circuit setups with citrate as the only anticoagulant. In two setups, the tandem procedures were connected in series (plasma exchange hemodialysis and immunoadsorption hemodialysis), while in the other two setups they were in parallel (plasma exchange hemodialysis with independent blood circuits and plasma exchange hemodialysis with independent arterial blood lines, but with a common return line). All tandem procedures were feasible, efficient and safe. No serious side-effects were recorded. The most elegant setup was the procedure with independent, parallel blood circuits. However, serial tandem procedures provided for the elimination of citrate and normalization of electrolytes before blood was returned to the patient.

Immunoadsorption and hemodialysis as a tandem procedure: a single-center experience of more than 60 procedures

PURPOSE

We have designed a desensitization program that gives good results and is cost effective for kidney-transplant patients who have a potential living donor, who are ABO incompatible (ABOi), and who may or may not have donor-specific alloantibodies (DSAs).

METHODS

Desensitization at pretransplant is based on immunosuppressants (such as rituximab, tacrolimus, and mycophenolic acid) and apheresis to retrieve potentially detrimental isoagglutinins and DSAs from blood. In 2011, we implemented immunoadsorption (IA) instead of plasmapheresis in our center as part of the desensitization protocol. Because IA is very tedious and time-consuming, we decided to perform IA and hemodialysis (HD) in tandem instead of performing these methods sequentially. Herein, we report on more than 100 of these tandem procedures and compare the results to those obtained when IA was performed before a HD session.

RESULTS

The tandem process resulted in nursing time being cut by half: from almost 10h30 min/patient to 6 h/patient. When IA was performed alone, body-weight gain was 1 kg (range 0 to 1.75) and the median volume of plasma treated per session was 6500 mL (range 4500 to 10 600). Conversely, during a tandem IA + HD session, the net median weight gain was -1.5 kg (range -4.1 to 0) and the median volume of plasma treated per session was 5000 mL (range 4000 to 8600). In addition, the tandem procedure was as well tolerated as that for IA followed by HD.

CONCLUSIONS

Tandem IA plus HD is a safe and cost-effective procedure.

Tandem hemodialysis and plasma exchange

The combination of hemodialysis and plasma exchange as one tandem procedure was first described in 1999 by Siami et al. (ASAIO J 45:229-233), but larger pediatric case series were not described until 2012. Even in adults, there are only limited case series. If performed in sequence, up to 8 h of treatment time may be required. With the use of the tandem procedure in stable patients, the same procedures can be completed during the same time as a routine hemodialysis, which is more convenient for patients and may reduce healthcare costs. Little is known about the utilization of the combination of hemodialysis and plasma exchange in children. The purpose of this review is to summarize the adult and scarce pediatric experience. The results of a survey carried out by the authors using the Internet listserver "PedNeph" to obtain an overview of the current practice patterns of pediatric nephrologists are also presented.

Safety and efficacy of tandem hemodialysis and plasma exchange in children

BACKGROUND AND OBJECTIVES

Patients with immune-mediated kidney disease and liver failure often require plasma exchange (PE) and hemodialysis (HD). Combining both methods (i.e., connecting the PE and HD circuits in series [tandem dialysis]) should allow for a more efficient treatment. This work reviews the authors' experience with tandem blood purification.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Chart review was utilized to retrospectively analyze the efficacy and tolerability of 92 combined PE/HD (cPE/HD) sessions in 26 children in comparison with 113 sequential PE/HD (sPE/HD) treatments performed in 32 children between 1988 and 2012 at the University of Heidelberg Center for Pediatric and Adolescent Medicine. Eleven children received both treatment modalities.

RESULTS

The mean treatment duration was 3.8 ± 2.2 hours per cPE/HD and 5.9 ± 1.6 hours per sPE/HD session (P<0.001). Dialyzer surface areas per body surface area (in meters squared) and blood flow rates were similar. Although a 3-fold higher initial bolus of heparin was administered with cPE/HD, the heparin dose per hour was similar with both modalities and the total heparin load was only slightly lower with cPE/HD, with a median 2939 IU/m(2) per session (interquartile range, 1868, 4189) versus 3341 IU/m(2) per session (interquartile range, 2126, 4792). In sessions with regional anticoagulation, equal citrate and calcium infusion rates were applied. Plasma turnover, ultrafiltration rates, and solute removal were comparable. Procedure-related problems developed in 14.0% of cPE/HD and 7.0% of sPE/HD sessions (P=0.37). Clinical symptoms occurred in 19.6% and 6.2% (P=0.05), necessitating treatment discontinuation in 12.0% and 5.3% of the sessions (P=0.14). Intra-individual comparison of both dialysis methods in 11 children reconfirmed these findings.

CONCLUSIONS

cPE/HD is a time-saving procedure relative to sPE/HD, but may be associated with a higher rate of procedure-related and clinical adverse events.

Tandem plasma-exchange and haemodialysis in a paediatric dialysis unit

BACKGROUND

The simultaneous use of plasma-exchange (PE) and haemodialysis (HD), known as tandem PE and HD (TPH), may be an additional resource for treating patients who need both therapies at the same time. However, little experience is reported in the paediatric setting.

CASE-DIAGNOSIS/TREATMENT

We retrospectively reviewed the TPH sessions performed in the last 5 years in our unit. Thirty-nine TPH treatments in eight pediatric patients were traced. The median age of the patients was 10.5 (range 5.1-19.2) years, and median weight was 27.6 (range 14.7-66.2) kg. Indications for TPH were atypical haemolytic uremic syndrome due to factor H or factor I dysregulation, or to a not yet defined abnormality, in most of the sessions (34/39 sessions). The remaining five sessions were performed for vasculitis, focal segmental glomerulosclerosis and hyperimmunization in a patient waiting for kidney transplant. In all treatments, TPH was completed and reached the desired ultrafiltration and substitution volumes; the duration of PE was shorter than that of HD. No significant adverse events were observed.

CONCLUSIONS

In those rare patients who require both PE and HD, TPH can improve their quality of life by reducing the time spent in extracorporeal circulation. This tandem treatment is safe and well-tolerated, even in subjects of relatively small body size.

Tandem plasmapheresis and hemodialysis: efficacy and safety

BACKGROUND

Hemodialysis (HD) and plasmapheresis (PE) are usually performed independently on patients who require renal replacement therapy. We analyzed our experience using a technique that performs both modalities simultaneously.

METHODS

Thirty-six patients who were treated with 287 tandem PE and HD (TPH) sessions (mean 7.97 ± 5.6 per patient) were included. PE was connected 30 min after HD started. The mean HD blood flow was 313.7 ± 44 mL/min, the mean PE blood flow was 141 ± 25 mL/min, and the duration of TPH was no longer than 240 min. The heparin dose was similar to that used for a standard HD procedure.

RESULTS

In 287 TPH sessions performed, 10.45% experienced minor complications. There were significant changes in mean blood pressure after connection of the PE system. However, these differences were not clinically relevant since patients remained asymptomatic and they did not require saline infusion. At the end of treatment, 38.9% of patients were no longer dependent on dialysis.

CONCLUSIONS

Our results suggest that TPH is a safe and effective treatment that decreases exposure to an extracorporeal circuit, reducing the risks that are associated with anticoagulation agents and improving the comfortability of the patient.

Rheologic reflection in hypertriglyceridemia-induced pancreatitis

Triglyceride levels greater than 1,000 mg/dL may cause severe pancreatitis, and there is mounting evidence for the use of plasmapheresis to remove triglycerides for the treatment of triglyceride-induced pancreatitis. The failure of continuous venovenous hemodialysis (CVVHD) due to severe lipemia, necessitating plasmapheresis in the early phase of severe acute hypertriglyceridemia-induced pancreatitis, is reported. We suggest that in the setting of hypertriglyceridemia-induced pancreatitis with urgent indication for dialysis, plasmapheresis be initiated prior to CVVHD to prevent rheologic failure.