Inefficacy of plasma exchange in cold agglutinin hemolytic anemia--a case study

Plasma exchanges do not increase red blood cell transfusion efficiency in severe autoimmune hemolytic anemia: A retrospective case-control study

Severe autoimmune hemolytic anemia (AIHA) can cause life-threatening hemolysis requiring red blood cell transfusions (RBT). The efficiency of RBT could be improved with the use of plasma exchanges (PEx) before RBT. The objective of this study was to assess the effectiveness of PEx in severe AIHA of adults. All adult patients with severe AIHA requiring RBT were included in this single center retrospective case-control study. The end point was change in hemoglobin (Hb) level after RBT, depending on whether PEx was done (experimental group) or not (control group). Thirty-one sessions of RBT following PEx were performed on the 5 patients of the experimental group and were compared with the 7 sessions of BT without PEx performed on the 4 patients of the control group. Despite a lower mean Hb value before the session of RBT (5.7 g/dl vs. 7.2 g/dl, P = 0.04) in the control group, the mean Hb value 5 (4-7) days following RBT (8.7 g/dl vs. 8.6 g/dl, P = 0.85) was not different in the experimental and in the control group, respectively. In a second analysis in which each patient was his own control (31 sessions of RBT following PEx vs. 51 sessions of RBT alone), the gain in Hb was not different (1.4 g/dl vs. 1.9 g/dl, P = 0.67). When RBT are required in severe AIHA of adults, the use of a single PEx before BT does not increase the efficiency of RBT based on day 5 evaluation.

Anti-Sa cold agglutinin of IgA class requiring plasma-exchange therapy as early manifestation of multiple myeloma

The case of a patient (Col) with multiple myeloma presenting as chronic cold agglutinin (CA) syndrome is reported. The CA (Col) was a monoclonal IgA/k paraprotein which recognizes an antigen fully expressed in adult and newborn erythrocytes, sialidase sensitive and partially resistant to proteases. Hemagglutination-inhibition studies showed that immunodominant N-acetylneuraminic acid bound alpha 2-->3 to O-glycans of glycophorins represents the CA(Col) epitope. These serological and biochemical findings fit with the anti-Sa specificity, of which only two previous examples are known. The clinical manifestations of CA (Col) were characterized by marked acrocyanosis, generalized livedo reticularis, and incapacitating dyspnea, but only mild hemolysis. Plasma-exchange therapy was effective in quickly removing the CA and relieving the associated clinical manifestations, but such benefit was only temporary. This is the first reported example of anti-Sa CA of IgA isotype and the first case of IgA CA syndrome treated by plasma exchange.

Benefit of a 37 degree C extracorporeal circuit in plasma exchange therapy for selected cases with cold agglutinin disease

Plasmapheresis is commonly advocated in cold agglutinin disease with life-threatening hemolysis. Some clinicians, however, are reluctant to use this therapy because of perceived technical problems and risks attendant with the temperature of the extracorporeal circulation. In this study we report our experience of two patients with severe life-threatening hemolysis and in whom plasma exchange was not feasible due to red blood cell autoagglutination in the extracorporeal circuit. A method is described involving the use of blood warmers and the Fenwal CS-3000 blood cell separator with its 37 degrees C centrifuge compartment. The use of plasma exchange in this manner is a safe and beneficial form of adjunctive therapy and should be considered for patients with cold agglutinin disease at risk for extracorporeal agglutination or hemolysis.

Plasma exchange treatment in autoimmune hemolytic anemia of the warm antibody type with renal failure

A patient with autoimmune hemolytic anemia of the warm antibody type developed a hyperacute hemolytic crisis with acute renal failure under conventional treatment with corticosteroids. Because of the life-threatening situation it was decided to start a combined treatment with immunosuppression and plasmapheresis. Already after the first plasma exchange the direct antiglobulin test became weakly positive, the hemoglobin level rose from 4.1 to 8.1 g/dl, and the hemolytic crisis subsided. Four more exchanges were performed; thereafter, the patient's clinical condition and laboratory data stabilized.