Plasma and plasma derivatives in therapeutic plasmapheresis

Albumin: a comprehensive review and practical guideline for clinical use

PURPOSE

Nowadays, it is largely accepted that albumin should not be used in hypoalbuminemia or for nutritional purpose. The most discussed indication of albumin at present is the resuscitation in shock states, especially distributive shocks such as septic shock. The main evidence-based indication is also liver disease. In this review, we provided updated evidence-based instruction for definite and potential indications of albumin administration in clinical practice, with appropriate dosing and duration.

METHODS

Data collection was carried out until November 2023 by search of electronic databases including PubMed, Google Scholar, Scopus, and Web of Science. GRADE system has been used to determine the quality of evidence and strength of recommendations for each albumin indication.

RESULTS

A total of 165 relevant studies were included in this review. Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, have a moderate to high quality of evidence and a strong recommendation for administering albumin. Moreover, albumin is used as a second-line and adjunctive to crystalloids for fluid resuscitation in hypovolemic shock, sepsis and septic shock, severe burns, toxic epidermal necrolysis, intradialytic hypotension, ovarian hyperstimulation syndrome, major surgery, non-traumatic brain injury, extracorporeal membrane oxygenation, acute respiratory distress syndrome, and severe and refractory edema with hypoalbuminemia has a low to moderate quality of evidence and weak recommendation to use. Also, in modest volume paracentesis, severe hyponatremia in cirrhosis has a low to moderate quality of evidence and a weak recommendation.

CONCLUSION

Albumin administration is most indicated in management of cirrhosis complications. Fluid resuscitation or treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments, is another rational use for albumin. Implementation of evidence-based guidelines in hospitals can be an effective measure to reduce inappropriate uses of albumin.

Therapeutic Plasma Exchange: For Cancer Patients

Therapeutic plasma exchange is used as a trial method for the treatment of cancer patients. Therapeutic plasma exchange uses in vitro technology to remove pathogenic factors in the plasma, returning the replacement and remaining components to the patient to facilitate cure. In the effort to explore new methods of cancer treatment, the introduction of therapeutic plasma exchange brings new hope for cancer treatment; however, the current evidence supporting therapeutic plasma exchange is controversial, and most of the evidence comes from observational studies, lacking large prospective randomized trials. Therefore, this review attempts to focus on the main indications of therapeutic plasma exchange for the treatment of tumors and their complications, including hematological tumors (multiple myeloma cast nephropathy and hyperviscosity syndrome), nervous system tumors (myasthenia gravis associated with thymoma, paraneoplastic neurological syndrome, Lambert–Eaton myasthenia syndrome, and anti-N-methyl-D-aspartate receptor encephalitis), overdose of chemotherapy drugs. In addition, the issues of side-effects and safety in the use of therapeutic plasma exchange are also discussed. However, well-designed prospective trials are needed to better define the role of therapeutic plasma exchange in cancer.

Extracellular vesicle therapeutics from plasma and adipose tissue

Extracellular vesicles (EVs) are cell-released lipid-bilayer nanoparticles that contain biologically active cargo involved in physiological and pathological intercellular communication. In recent years, the therapeutic potential of EVs has been explored in various disease models. In particular, mesenchymal stromal cell-derived EVs have been shown to exert anti-inflammatory, anti-oxidant, anti-apoptotic, and pro-angiogenic properties in cardiovascular, metabolic and orthopedic conditions. However, a major drawback of EV-based therapeutics is scale-up issues due to extensive cell culture requirements and inefficient isolation protocols. An emerging alternative approach to time-consuming and costly cell culture expansion is to obtain therapeutic EVs directly from the body, for example, from plasma and adipose tissue. This review discusses isolation methods and therapeutic applications of plasma and adipose tissue-derived EVs, highlighting advantages and disadvantages compared to cell culture-derived ones.

Evaluation of membrane-based therapeutic plasma exchange as adjunctive treatment for immune-mediated hematologic disorders in dogs

Background

Therapeutic plasma exchange (TPE) has been used increasingly to treat immunological diseases in dogs, although data concerning its efficacy are lacking.

Hypothesis/Objectives

To describe the clinic and the outcome of dogs with immune‐mediated hematological disorders (IMHD) treated with membrane filtration TPE.

Animals

One hundred forty‐six dogs diagnosed with IMHD, including 17 dogs treated with and 129 control dogs treated without TPE.

Methods

Retrospective study of cases selected with a search of all medical records for dogs diagnosed with IMHD (2010‐2019). Primary outcomes included the assessment of safety and efficacy of adjunctive TPE compared to medical treatment alone.

Results

The TPE group included 7 dogs with immune‐mediated hemolytic anemia (IMHA), 5 dogs with immune‐mediated thrombocytopenia (IMT), and 5 dogs with combined IMHA‐IMT; the control group included 63 dogs with IMHA, 47 dogs with IMT, and 19 dogs with IMHA‐IMT. Dogs treated with TPE were more often refractory to initial immunosuppression (71%) than controls (43%; P = .04). Complications were observed in 15/43 TPE treatments (35%). The response rate of dogs treated with TPE was 83% in IMHA (controls, 65%; P = .5) and 80% in IMT (controls, 70%; P = .71). Overall, 12/17 dogs (71%) treated with TPE reached complete remission, 2/17 (12%) partial remission, and 3/17 (18%) died or were euthanized. Eighty‐two percent of the dogs treated with TPE survived to discharge (controls, 69%; P = .4).

Conclusions and Clinical Importance

Despite a bias toward dogs refractory to initial immunosuppression, dogs treated with adjunctive TPE had a similar outcome as dogs treated medically.

Beyond cells: The extracellular circulating 20S proteasomes

Accumulating evidence arising from numerous clinical studies indicate that assembled and functional 20S proteasome complexes circulate freely in plasma. Elevated levels of this core proteolytic complex have been found in the plasma of patients suffering from blood, skin and solid cancers, autoimmune disorders, trauma and sepsis. Moreover, in various diseases, there is a positive correlation between circulating 20S proteasome (c20S) levels and treatment efficacy and survival rates, suggesting the involvement of this under-studied c20S complex in pathophysiology. However, many aspects of this system remain enigmatic, as we still do not know the origin, biological role or mechanisms of extracellular transport and regulation of c20S proteasomes. In this review, we provide an overview of the current understanding of the c20S proteasome system and discuss the remaining gaps in knowledge.

Systemic Lupus Erythematosus Treatment in Pregnancy: Case Study

Systemic lupus erythematosus is a chronic inflammatory autoimmune disease with high prevalence in female in reproductive age. In recent years the prognosis of pregnant patients with SLE has improved significantly. Even though the treatment options have improved, the risk of flares, preeclampsia, pregnancy loss, and premature labours remains high compared to healthy women. The aim of this article is to offer a review of current treatment options in pregnant patients with SLE and to present a case report of 32-year-old patient with newly diagnosed acute outbreak of SLE, who experienced a life-threatening multisystem flare at 24 weeks of gestational age. This case represents one of the most extreme manifestations of lupus disease activity associated with pregnancy that has been reported in literature and emphasizes the importance of preconception evaluation and counseling and amultidisciplinary management approach in cases with a complex and evolving clinical course.

Recommendations for Therapeutic Apheresis by the Section "Preparative and Therapeutic Hemapheresis" of the German Society for Transfusion Medicine and Immunohematology

The section "Preparative and Therapeutic Hemapheresis" of the German Society for Transfusion Medicine and Immunohematology (DGTI) has reviewed the actual literature and updated techniques and indications for evidence-based use of therapeutic apheresis in human disease. The recommendations are mostly in line with the "Guidelines on the Use of Therapeutic Apheresis in Clinical Practice" published by the Writing Committee of the American Society for Apheresis (ASFA) and have been conducted by experts from the DACH (Germany, Austria, Switzerland) region.

Therapeutic plasma exchange in hypertriglyceridemic patients

Background/aim

High triglyceride (TG) levels are associated with increases in atherosclerotic cardiovascular disease (CVD), hepatic steatosis, and pancreatitis. Acute pancreatitis is a condition with high mortality. Therapeutic plasma exchange (TPE) in the treatment of hypertriglyceridemic pancreatitis (HTGP) is a rapid and effective treatment modality. In this study, the results of TPE were evaluated and the frequency of lipoprotein lipase (LPL) mutation in these patients was determined.

Materials and methods

TPE was performed in 31 patients with HTGP at the Adult Therapeutic Apheresis Center.

Results

A TG level under 500 mg/dL was achieved by applying apheresis at a median of 2 times (IQR 2–2, min 1, max 6) in the 31 cases. LPL mutation was detected in 8 (25.8%) of the 31 hypertriglyceridemia cases. When TG levels before and after TPE were evaluated, the mean TG level before TPE was significantly higher (3132 ± 1472 mg/dL) than the mean TG level afterwards (948 ± 465 mg/dL, P < 0.001). This result represented a decrease of 69.7% TG after TPE.

Conclusion

TPE is a safe, fast, and effective treatment modality in experienced centers.

Weathering the Crisis: A Case of Thyroid Crisis with Propranolol-Induced Circulatory Collapse Successfully Treated with Therapeutic Plasma Exchange

Thyroid crisis is a life-threatening form of thyrotoxicosis characterized by multi-system dysfunction. Therapeutic plasma exchange has been reported to be effective in removing excessive circulating thyroid hormones. We present a 46-year-old female with recently diagnosed Graves’ disease associated with thyrotoxic cardiomyopathy admitted for thyroid crisis complicated by propranolol-induced circulatory collapse, acute kidney injury and ischemic hepatitis. The tachyarrhythmia was refractory to conventional therapy. Initiation of TPE resulted in rapid clinical and biochemical stabilization.

Therapeutic plasmapheresis in thyrotoxic patients

PURPOSE

For the treatment of thyrotoxicosis, alternative treatment modalities may be necessary if anti-thyroid drugs cannot be used due to side effects, inefficiencies, or there is a need to start a rapid action such as thyroid storm. By using therapeutic plasma exchange (TPE), it is possible to effectively and rapidly remove the increased thyroid hormones. We evaluated our results and experience on a rapid, effective, and reliable alternative treatment modality in thyrotoxic patients.

METHODS

TPE was performed in 46 thyrotoxic patients at the Adult Therapeutic Apheresis Center.

RESULTS

Forty six patients with a median age of 30 years (interquartile range [IQR] 30-50) were assessed. In 40 (87%) of the cases, the diagnosis was Graves' disease. The other causes of thyrotoxicosis were amiodarone-induced thyrotoxicosis (n = 4) and toxic nodular goiter (n = 2). The median and IQR of fT3 values in patients before TPE were 9.9 (6.5-16.8) pg/mL (N: 2.3-4.2) and the median and IQR of fT4 values were 2.9 (2.3-4.1) ng/dL (N: 0.74-1.52). When the procedure was terminated, the median and IQR of fT3 values in patients were 4.0 (3.1-5.2) pg/mL and the median and IQR fT4 values were 1.6 (1.4-2.0) ng/dL. The decrease in both free thyroid hormones was found to be statistically significant (p < 0.000).

CONCLUSION

Our study is the largest series of TPE in the literature used for thyrotoxicosis. In the light of the literature and our results, we conclude that TPE is an effective alternative treatment option to prepare for ablative treatment for cases that have side effects or ineffectiveness of anti-thyroid drugs.

Plasmapheresis and other extracorporeal filtration techniques in critical patients

Plasmapheresis is an extracorporeal technique that eliminates macromolecules involved in pathological processes from plasma. A review is made of the technical aspects, main indications in critical care and potential complications of plasmapheresis, as well as of other extracorporeal filtration techniques such as endotoxin-removal columns and other devices designed to eliminate cytokines or modulate the inflammatory immune response in critical patients.

Cross-Sectional Guidelines for Therapy with Blood Components and Plasma Derivatives: Chapter 5 Human Albumin - Revised

Chapter 5 'Human Albumin' that was suspended on January 10, 2011 has been completed and updated in the present version.

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis--A Comprehensive Review and Guide to Therapy. I. Systemic Disease

The intent of this review is to comprehensively appraise the state of the art with regard to Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to the ocular surface complications and their management. SJS and TEN represent two ends of a spectrum of immune-mediated, dermatobullous disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. The widespread keratinocyte death seen in SJS/TEN is rapid and irreversible, and even with early and aggressive intervention, morbidity is severe and mortality not uncommon. We have divided this review into two parts. Part I summarizes the epidemiology and immunopathogenesis of SJS/TEN and discusses systemic therapy and its possible benefits. We hope this review will help the ophthalmologist better understand the mechanisms of disease in SJS/TEN and enhance their care of patients with this complex and often debilitating disease. Part II (April 2016 issue) will focus on ophthalmic manifestations.

Efficacy of plasma exchange and immunoadsorption in systemic lupus erythematosus and antiphospholipid syndrome: A systematic review

Extracorporeal treatments have been used since the 1970s in the management of systemic lupus erythematosus (SLE). A randomised controlled trial comparing the efficacy of standard of care (SOC) combined with plasma exchange against SOC alone in patients with lupus nephritis revealed no difference in terms of renal outcome. Subsequently, initial expectations have been dampened and further experience with plasma exchange is mainly limited to observational studies and single case reports. Beneficial effects have been reported in patients with refractory disease course or in pregnancy with prior complications due to SLE and antiphospholipid syndrome. A more specific form of extracorporeal treatment, immunoadsorption (IAS), has emerged as a valuable option in the treatment of SLE. In line with the plasma exchange experience, IAS seems to have beneficial effects in patients with refractory disease, contraindications to standard immunosuppression or during pregnancy. The mechanism IAS relates to autoantibody removal but for plasma exchange removal of activated complement components, coagulation factors, cytokines and microparticles may also be relevant. Both treatment forms have good safety profiles although reactions to blood product replacement in plasma exchange and procedure related complications such as bleeding or catheter-related infections have occurred. There is a need to more clearly define the clinical utility of plasma exchange and IAS in refractory lupus and APS subgroups.

Assessment of Hemostasis after Plasma Exchange Using Rotational Thrombelastometry (ROTEM)

Background

Therapeutic plasma exchange (TPE)-based protocols immediately before cadaveric donor kidney transplantation have been extensively used in highly sensitized recipients. Plasma is generally preferred over human albumin as replacement fluid to avoid depletion of coagulation factors and perioperative bleeding. The aim of this study was to estimate bleeding risk after TPE replaced with albumin using rotational thromboelastography (ROTEM).

Methodology

Ten patients without overt coagulation abnormalities underwent TPE. Standard laboratory coagulation tests (thromboplastin time, activated partial thromboplastin time (aPTT), international normalized ratio (INR), thrombin clotting time, fibrinogen levels and antithrombin activity) were compared with thrombelastometry analysis (EXTEM and INTEM tests) before and after TPE.

Principal Findings

TPE significantly reduced fibrinogen levels (482 ± 182 vs. 223 ± 122 mg/dL), antithrombin activity (103 ± 11 vs. 54 ± 11 %), and prolonged aPTT (28 ± 3 vs. 45 ± 8 s), thromboplastin time (108 ± 11 vs. 68 ± 11 %), INR (0.95 ± 0.06 vs. 1.25 ± 0.16), and thrombin clotting time (18 ± 2 vs. 20 ± 3 s). INTEM and EXTEM analyses revealed significantly prolonged clot-formation time and reduced maximum clot firmness.

Conclusions/Significance

TPE replaced with albumin induces significant changes in global hemostasis parameters thus potentially increasing bleeding risk. Therefore, pretransplant TPE should be considered carefully in indicated patients before kidney transplantation. The role of the ROTEM point-of-care test to estimate the risk of bleeding in renal transplantation needs to be evaluated in further studies.

The ABC of apheresis

Apheresis is a collective term for several activities in which a desirable specific blood component is separated and collected or a harmful component is removed. During the last decades the application of apheresis has expanded to a broad spectrum of diseases due to various studies on the clinical efficacy of this therapy as well as the innovation of new techniques. However, adverse events quite often occur during apheresis. In this article we will give a brief overview on general principles, indications and complications of apheresis.

Patients treated with therapeutic plasma exchange: a single center experience

INTRODUCTION

Therapeutic Plasma Exchange (TPE) is a therapeutic procedure that is used to remove high molecular weight substances from plasma. We analyzed data of patients who received TPE during the last 7 years, and focused on the efficiency of TPE in various disease groups.

MATERIAL AND METHODS

We studied 110 patients treated with TPE by membrane plasma separation technique from 2007 to 2013. We examined the demographic data, underlying disease, biochemical parameters, volume and type of replacement fluid, complications, concomitant treatment, the need for hemodialysis and number of TPE sessions.

RESULTS

One hundred ten patients, 58 male, 52 female were included. The mean age was 47.3 ± 17.6 years. A total of 734 TPE sessions were performed and the mean number of TPE sessions per patient was 6.6 ± 4.3. The underlying disease was renal transplantation in 26 patients, ANCA-associated vasculitis in 18, rapidly progressive glomerulonephritis in 17, hemolytic uremic syndrome in 11, thrombotic thrombocytopenic purpura in 9, autoimmunic hemolytic anemia in 6, focal segmental glomerulosclerosis in 6 and other diseases. Partial and complete remission was obtained in 65 (59.1%) and 24 patients (21.8%) respectively, while 14 (12.7%) patients had no response and 7 (6.4%) patients died. Complications were muscle cramps (6.4%), allergic reactions (4.5%), severe hypotension (3.6%), fever (1.8%), unconsciousness (0.9%), leukopenia (0.9%) and catheter related hematoma (0.9%).

CONCLUSION

According to our 7 years of experience in TPE, we can say that therapeutic plasma exchange by membrane separation technique is a useful, easy, available and effective life-saving therapeutic treatment.