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Cilek N, Ugurel E, Eren OC, Yalcin O, Akay OM. A global assessment of hemostatic function of healthy allogeneic stem cell donors undergoing apheresis by rotational thromboelastometry. Ther Apher Dial 2024; 28:657-663. [PMID: 38462734 DOI: 10.1111/1744-9987.14120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/13/2024] [Accepted: 02/26/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Peripheral blood stem cell (PBSC) collection via apheresis requires the administration of granulocyte colony-stimulating factor (filgrastim) to stem cell donors. Several reports have shown that filgrastim administration and apheresis procedure induce a hypercoagulable state across PBSC collection, which might predispose certain donors to thrombotic complications. METHODS We evaluated the hemostatic functions of healthy allogeneic stem cell donors by rotational thromboelastometry (ROTEM). Blood samples from healthy donors (n = 30) were collected at defined time points: before filgrastim (baseline), on the day of apheresis before and after the procedure, and 1 week after apheresis. RESULTS The results indicated that hemostatic changes are temporary since all parameters in both EXTEM and INTEM assays are restored to their initial values 1 week after the apheresis. CONCLUSION We concluded that stem cell apheresis does not induce a hypercoagulable state in healthy donors. This is the first study evaluating the hemostatic functions of stem cell donors by ROTEM.
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Affiliation(s)
- Neslihan Cilek
- Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey
- Graduate School of Health Sciences, Koc University, Istanbul, Turkey
| | - Elif Ugurel
- Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey
- Department of Physiology, School of Medicine, Koc University, Istanbul, Turkey
| | - Ozgur Can Eren
- Department of Pathology, Koc University Hospital, Istanbul, Turkey
| | - Ozlem Yalcin
- Research Center for Translational Medicine (KUTTAM), Koc University, Istanbul, Turkey
- Department of Physiology, School of Medicine, Koc University, Istanbul, Turkey
| | - Olga Meltem Akay
- Department of Haematology, Koc University Hospital, Istanbul, Turkey
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Baykara Y, Nixon C, Pavlovich A, Akgun Y. Unpacking the utility of euvolemic automated transfusion in sickle cell disease. Transfusion 2024; 64:1381-1382. [PMID: 39010682 DOI: 10.1111/trf.17875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 07/17/2024]
Affiliation(s)
- Yigit Baykara
- Department of Pathology and Laboratory Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Christian Nixon
- Department of Pathology and Laboratory Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Andriana Pavlovich
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Yamac Akgun
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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Saddoughi SA, Martinu T, Patriquin C, Barth D, Huszti E, Ghany R, Tinckam K, McRae K, Singer LG, Keshavjee S, Cypel M, Aversa M. Impact of intraoperative therapeutic plasma exchange on bleeding in lung transplantation. J Heart Lung Transplant 2024; 43:414-419. [PMID: 37813131 DOI: 10.1016/j.healun.2023.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/21/2023] [Accepted: 10/02/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Our program uses a desensitization protocol that includes intraoperative therapeutic plasma exchange (iTPE) for crossmatch-positive lung transplants, which improves access to lung transplant for sensitized candidates while mitigating immunologic risk. Although we have reported excellent outcomes for sensitized patients with the use of this protocol, concern for perioperative bleeding appears to have hindered broader adoption of it at other programs. We conducted a retrospective cohort study to quantify the impact of iTPE on perioperative bleeding in lung transplantation. METHODS All first-time lung transplant recipients from 2014 to 2019 who received iTPE were compared to those who did not. Multivariable logistic regression was used to determine the association between iTPE and large-volume perioperative transfusion requirements (≥5 packed red blood cell units within 24 hours of transplant start), adjusted for disease type, transplant type, and extracorporeal membrane oxygenation or cardiopulmonary bypass use. The incidence of hemothorax (requiring reoperation within 7 days of lung transplant) and 30-day posttransplant mortality were compared between the 2 groups using chi-square test. RESULTS One hundred forty-two patients (16%) received iTPE, and 755 patients (84%) did not. The mean number of perioperative pRBC transfusions was 4.2 among patients who received iTPE and 2.9 among patients who did not. iTPE was associated with increased odds of requiring large-volume perioperative transfusion (odds ratio 1.9; 95% confidence interval: 1.2-2.9, p-value = 0.007) but was not associated with an increased incidence of hemothorax (5% in both groups, p = 0.99) or 30-day posttransplant mortality (3.5% among patients who received iTPE vs 2.1% among patients who did not, p = 0.31). CONCLUSIONS This study demonstrates that the use of iTPE in lung transplantation may increase perioperative bleeding but not to a degree that impacts important posttransplant outcomes.
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Affiliation(s)
- Sahar A Saddoughi
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Tereza Martinu
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Christopher Patriquin
- Division of Medical Oncology & Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - David Barth
- Division of Medical Oncology & Hematology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Kathryn Tinckam
- Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Karen McRae
- Department of Anesthesia and Pain Management, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Lianne G Singer
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Meghan Aversa
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada.
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Ferreira AS, Maux Lessa MP, Sanborn K, Kuchibhatla M, Karafin MS, Onwuemene OA. In hospitalized patients undergoing therapeutic plasma exchange, major bleeding prevalence depends on the bleeding definition: An analysis of The Recipient Epidemiology and Donor Evaluation Study-III. J Clin Apher 2023; 38:694-702. [PMID: 37548357 PMCID: PMC10841207 DOI: 10.1002/jca.22080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Major bleeding in patients undergoing therapeutic plasma exchange (TPE) has been studied in large databases; but without standardizing bleeding definitions. Therefore, we used standardized definitions to evaluate major bleeding in hospitalized patients undergoing TPE using public use data files from the Recipient Epidemiology and Donor Evaluation Study-III (REDS-III). STUDY DESIGN AND METHODS In a retrospective cross-sectional analysis, we identified TPE-treated adults in a first inpatient encounter. We evaluated major bleeding prevalence using (1) International Classification of Diseases (ICD) or Current Procedural Terminology (CPT) codes, (2) packed red blood cell (PRBC) transfusion, or (3) hemoglobin (Hgb) decline. Patients with major bleeding prior to their first TPE were excluded from the analysis. RESULTS Among 779 patients undergoing TPE, major bleeding by at least one of the three bleeding definitions occurred in 135 patients (17.3%). For each of the ICD/CPT, PRBC, and Hgb definitions, the prevalence of major bleeding was 2.8% (n = 31), 7.4% (n = 81), and 5.4% (n = 59), respectively. Only 3.7% of bleeds (5/135) were captured by all three definitions and 19.3% (26/135) exclusively by any two pairwise definitions. The addition of PRBC transfusion and Hgb decline to ICD/CPT code definitions increased bleeding prevalence threefold. CONCLUSION Among hospitalized adults undergoing TPE in the REDS-III study, the prevalence of major bleeding was 17.3%. The addition of PRBC and Hgb decline to ICD codes increased bleeding prevalence threefold. Future studies are needed to develop validated models that identify patients at risk for major bleeding during TPE.
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Affiliation(s)
- Alexandre Soares Ferreira
- Department of Medicine, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, São Paulo, Brazil
| | - Morgana Pinheiro Maux Lessa
- Department of Medicine, Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, São Paulo, Brazil
| | - Kate Sanborn
- Duke Biostatistics, Epidemiology and Research Design Core, Duke University School of Medicine, Durham, North Carolina, USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew S Karafin
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Oluwatoyosi A. Onwuemene
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Grifols C, Barceló M, Núñez L, Szczepiorkowski ZM, Boada M, López OL, Páez A. Impact of therapeutic and low volume plasma exchange on clinical laboratory parameters in patients treated for Alzheimer's disease from the AMBAR study. Ther Apher Dial 2023; 27:949-959. [PMID: 37211527 DOI: 10.1111/1744-9987.14002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/20/2022] [Accepted: 05/06/2023] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Little is known about the impact of plasma exchange (PE) on clinical laboratory parameters in Alzheimer's disease (AD) patients. METHODS AD patients in the AMBAR trial (N = 322) received weekly therapeutic PE (TPE) for 6 weeks followed by monthly low-volume PE (LVPE) for12 months. Treatment were placebo (sham PE), low-albumin, low-albumin + IVIG (i.e., albumin alternated with intravenous immunoglobulin) and high-albumin + IVIG. RESULTS Coagulation parameters transiently increased post-TPE. Blood calcium, platelets, and albumin levels decreased but remained within the reference range. Leukocyte counts increased. Fibrinogen, hemoglobin, total protein, gamma globulin, and IgG, transiently dipped below the reference range. Hypogammaglobulinemia (7.2 g/L) persisted in pre-TPE measurements. No changes were observed during the LVPE period. Cerebrospinal fluid parameters and vital signs were unchanged throughout. CONCLUSION Laboratory parameters of AD patients were affected by TPE similarly to effects of PE-treatment for other pathologies. These effects were less pronounced or non-existent for LVPE.
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Affiliation(s)
| | - Miquel Barceló
- Alzheimer's Research Group, Grifols S.A., Barcelona, Spain
| | - Laura Núñez
- Alzheimer's Research Group, Grifols S.A., Barcelona, Spain
| | - Zbigniew M Szczepiorkowski
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Division of Transfusion Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Mercè Boada
- Ace Alzheimer Center Barcelona, Universitat Internacional de Catalunya, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
| | - Oscar L López
- Departments of Neurology and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Antonio Páez
- Alzheimer's Research Group, Grifols S.A., Barcelona, Spain
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Bauer PR, Ostermann M, Russell L, Robba C, David S, Ferreyro BL, Cid J, Castro P, Juffermans NP, Montini L, Pirani T, Van De Louw A, Nielsen N, Wendon J, Brignier AC, Schetz M, Kielstein JT, Winters JL, Azoulay E. Plasma exchange in the intensive care unit: a narrative review. Intensive Care Med 2022; 48:1382-1396. [PMID: 35960275 PMCID: PMC9372988 DOI: 10.1007/s00134-022-06793-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/20/2022] [Indexed: 02/04/2023]
Abstract
In this narrative review, we discuss the relevant issues of therapeutic plasma exchange (TPE) in critically ill patients. For many conditions, the optimal indication, device type, frequency, duration, type of replacement fluid and criteria for stopping TPE are uncertain. TPE is a potentially lifesaving but also invasive procedure with risk of adverse events and complications and requires close monitoring by experienced teams. In the intensive care unit (ICU), the indications for TPE can be divided into (1) absolute, well-established, and evidence-based, for which TPE is recognized as first-line therapy, (2) relative, for which TPE is a recognized second-line treatment (alone or combined) and (3) rescue therapy, where TPE is used with a limited or theoretical evidence base. New indications are emerging and ongoing knowledge gaps, notably regarding the use of TPE during critical illness, support the establishment of a TPE registry dedicated to intensive care medicine.
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Affiliation(s)
- Philippe R. Bauer
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
| | - Marlies Ostermann
- Department of Critical Care, King’s College London, Guy’s & St Thomas’ Hospital, London, UK
| | - Lene Russell
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino, Genoa, Italy
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Bruno L. Ferreyro
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Joan Cid
- Unitat d’Afèresi i Teràpia Cel·lular, Banc de Progenitors Hematopoètics, Servei d’Hemoteràpia i Hemostàsia, ICMHO, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Nicole P. Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Luca Montini
- Department of Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Tasneem Pirani
- Critical Care Unit, King’s College Hospital NHS Foundation Trust, London, UK
| | | | - Nathan Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine, University of New Mexico School of Medicine, New Mexico, USA
| | - Julia Wendon
- Institute of Liver Studies, King’s College Hospital NHS Foundation Trust, London, UK
| | - Anne C. Brignier
- Apheresis Unit, Immuno-Hematology, Hôpital Saint-Louis, APHP, Paris, France
| | - Miet Schetz
- Division of Cellular and Molecular Medicine, Clinical Department and Laboratory of Intensive Care Medicine, KU Leuven University, Leuven, Belgium
| | - Jan T. Kielstein
- Nephrology | Rheumatology | Blood Purification, Academic Teaching Hospital Braunschweig, Brunswick, Germany
| | - Jeffrey L. Winters
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, USA
| | - Elie Azoulay
- Médecine Intensive et Réanimation, Hôpital Saint-Louis, APHP, Paris, France
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Soares Ferreira Júnior A, Hodulik K, Barton KD, Onwuemene OA. Hemostatic effects of therapeutic plasma exchange: A concise review. J Clin Apher 2022; 37:292-312. [PMID: 35196407 DOI: 10.1002/jca.21973] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/21/2022] [Accepted: 02/03/2022] [Indexed: 01/16/2023]
Abstract
Therapeutic plasma exchange (TPE) alters the hemostatic balance. Contributing to TPE's hemostatic effects is the mechanical processing of blood in the extracorporeal circuit, circuit anticoagulant, type of replacement fluid, TPE schedule and number of procedures, TPE timing relative to invasive procedures, and removal of nontargeted components such as platelets, coagulation proteins, and cytokines. Although TPE's hemostatic effects are well established, how it impacts the bleeding risk is not clearly understood. In this concise review, we describe the effects of the above TPE-related factors on hemostatic balance, present data on the effects of TPE on blood hemostasis, including its effects on platelet counts and clotting assays, and review the literature on the impact of TPE-induced hemostatic changes on TPE-associated bleeding events. Finally, we discuss risk factors associated with bleeding during TPE and review the literature on TPE-associated hemostatic effects in the pediatric population.
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Affiliation(s)
| | - Kimberly Hodulik
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA.,Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Karen D Barton
- Medical Center Library & Archives, Duke University Medical Center, Durham, North Carolina, USA
| | - Oluwatoyosi A Onwuemene
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Soares Ferreira Júnior A, Boyle SH, Kuchibhatla M, Onwuemene OA. Bleeding outcomes of inpatients receiving therapeutic plasma exchange: A propensity-matched analysis of the National Inpatient Sample. Transfusion 2021; 62:386-395. [PMID: 34907537 DOI: 10.1111/trf.16769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/10/2021] [Accepted: 11/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although therapeutic plasma exchange (TPE) is associated with hemostatic abnormalities, its impact on bleeding outcomes is unknown. Therefore, the main study objective was to determine bleeding outcomes of inpatients treated with TPE. STUDY DESIGN AND METHODS In a cross-sectional analysis of the National Inpatient Sample (NIS), discharges were identified with 10 common TPE-treated conditions. A 1:3 propensity-matched analysis of TPE- to non-TPE-treated discharges was performed. The primary outcome was major bleeding and secondary outcomes were packed red blood cell (PRBC) transfusion, mortality, disposition, hospital length of stay (LOS), and charges. Multivariable regression analyses were used to examine the association between TPE and study outcomes. RESULTS The study population was 15,964 discharges, of which 3991 were TPE- treated. The prevalence of major bleeding was low (5.4%). When compared to non-TPE discharges, TPE had a significant and positive association with major bleeding (OR = 1.37, 95% CI: 1.16-1.63, p = .0003). TPE was also associated with PRBC transfusion (OR = 1.66, 95% CI: 1.42-1.94, p < .0001), in-hospital mortality (OR = 1.45, 95% CI: 1.10-1.90, p = .0008), hospital length of stay (12.45 [95% CI: 11.95-12.97] vs. 7.38 [95% CI: 7.12-7.65] days, p < .0001) and total charges, ($125,123 [95% CI: $119,220-$131,317] vs. $61,953 [95% CI: $59,391-$64,625], p < .0001), and disposition to non-self-care (OR = 1.29, 95% CI: 1.19-1.39, p < .0001). DISCUSSION The use of TPE in the inpatient setting is positively associated with bleeding; however, with low prevalence. Future studies should address risk factors that predispose patients to TPE-associated bleeding.
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Affiliation(s)
| | - Stephen H Boyle
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Oluwatoyosi A Onwuemene
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Hanley C, Callum J, Karkouti K, Bartoszko J. Albumin in adult cardiac surgery: a narrative review. Can J Anaesth 2021; 68:1197-1213. [PMID: 33884561 DOI: 10.1007/s12630-021-01991-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Intravascular fluids are a necessary and universal component of cardiac surgical patient care. Both crystalloids and colloids are used to maintain or restore circulating plasma volume and ensure adequate organ perfusion. In Canada, human albumin solution (5% or 25% concentration) is a colloid commonly used for this purpose. In this narrative review, we discuss albumin supply in Canada, explore the perceived advantages of albumin, and describe the clinical literature supporting and refuting albumin use over other fluids in the adult cardiac surgical population. SOURCE We conducted a targeted search of PubMed, Embase, Medline, Web of Science, ProQuest Dissertations and Theses Global, the Cochrane Central Register of Controlled trials, and the Cochrane Database of Systematic Reviews. Search terms included albumin, colloid, cardiac surgery, bleeding, hemorrhage, transfusion, and cardiopulmonary bypass. PRINCIPAL FINDINGS Albumin is produced from fractionated human plasma and imported into Canada from international suppliers at a cost of approximately $21 million CAD per annum. While it is widely used in cardiac surgical patients across the country, it is approximately 30-times more expensive than equivalent doses of balanced crystalloid solutions, with wide inter-institutional variability in use and no clear association with improved outcomes. There is a general lack of high-quality evidence for the superiority of albumin over crystalloids in this patient population, and conflicting evidence regarding safety. CONCLUSIONS In cardiac surgical patients, albumin is widely utilized despite a lack of high- quality evidence supporting its efficacy or safety. A well-designed randomized controlled trial is needed to clarify the role of albumin in cardiac surgical patients.
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Affiliation(s)
- Ciara Hanley
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street 3EN-464, Toronto, ON, M5G 2C4, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street 3EN-464, Toronto, ON, M5G 2C4, Canada.
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Soares Ferreira Júnior A, Boyle SH, Kuchibhatla M, Akinyemiju T, Onwuemene OA. Use of therapeutic plasma exchange in heparin-induced thrombocytopenia: A population-based study. J Clin Apher 2021; 36:398-407. [PMID: 33453132 DOI: 10.1002/jca.21876] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/06/2021] [Accepted: 01/06/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is characterized by anti-heparin/platelet factor 4 immune complexes, which are removed by therapeutic plasma exchange (TPE). Our main objective was to study TPE outcomes in HIT using a large administrative claims database. STUDY DESIGN AND METHODS We used the National Inpatient Sample (NIS) to identify hospital discharges of adult patients (≥18) with a primary or secondary diagnosis of HIT. Cases were classified into two groups based on TPE use. The primary outcome was in-hospital mortality. Secondary outcomes were thrombotic events, major bleeding, hospital length of stay (LOS), and charges. Multivariable regression analysis, controlling for age and medical comorbidities, was used to examine the association of TPE with study outcomes. RESULTS A HIT diagnosis was made in 22 165 discharges, of which 90 (0.4%) received TPE. Corresponding national estimates are 106 435 and 439, respectively. TPE was not associated with decreased in-hospital mortality (OR = 1.72; 95%CI: 0.93-3.17, P = .085). However, TPE was associated with a higher likelihood of major bleeding (OR = 2.35; 95%CI: 1.40-3.68, P = .0009), primarily driven by gastrointestinal bleeding (OR = 2.21; 95%CI: 1.17-4.17, P = .015). TPE was also associated with higher hospital LOS (20.5 vs 10 day, P < .0001) and charges (USD 211181 vs USD 81654, P < .0001). CONCLUSION TPE's association with increased bleeding and a prolonged hospital course indicates that it is being used in HIT cases with a severe clinical phenotype. Future studies are needed to better characterize the HIT phenotype that will most benefit from TPE.
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Affiliation(s)
| | - Stephen H Boyle
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tomi Akinyemiju
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Oluwatoyosi A Onwuemene
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Zhang R, Dahl AB, Marchant B, Jackups RR, Karnes HE, Shah P, Dynis M, Thibodeaux SR, Despotis GJ. Optimizing management of replacement fluids for therapeutic plasma exchange: Use of an automated mathematical model to predict post-procedure fibrinogen and antithrombin levels in high-risk patients. J Clin Apher 2019; 35:41-49. [PMID: 31713919 DOI: 10.1002/jca.21758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 08/22/2019] [Accepted: 09/28/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) utilizes an extracorporeal circuit to remove pathologic proteins causing serious illness. When processing a patient's entire blood volume through an extracorporeal circuit, proteins responsible for maintaining hemostatic system homeostasis can reach critically low levels if replacement fluid types and volumes are not carefully titrated, which may increase complications. METHODS The charts from 27 patients undergoing 46 TPE procedures were reviewed to evaluate the accuracy of our predictive mathematical model, utilizing the following patient information: weight, hematocrit, pre- and post-TPE factor levels (fibrinogen, n = 46, and antithrombin, n = 23), process volume and volumes of fluids (eg, plasma, albumin, and normal saline) administered during TPE and adverse events during and after TPE. RESULTS Altogether, 25% of patients experienced minor adverse events that resolved spontaneously or with management. There were no bleeding or thrombotic complications. The mean difference between predicted and measured post-TPE fibrinogen concentrations was -0.29 mg/dL (SD ±23.0, range -59 to 37), while percent difference between measured and predicted fibrinogen concentration was 0.94% (SD ±10.8, range of -22 to 19). The mean difference between predicted and measured post-TPE antithrombin concentrations were 0.89% activity (SD ±10.0, range -23 to 14), while mean percent difference between predicted and measured antithrombin concentrations was 3.87% (SD ±14.5, range -25 to 38). CONCLUSIONS Our model reliably predicts post-TPE fibrinogen and antithrombin concentrations, and may help optimize patient management and attenuate complications.
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Affiliation(s)
- Ray Zhang
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Aaron B Dahl
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, Illinois
| | - Bryan Marchant
- Department of Anesthesiology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | - Ronald R Jackups
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Hope E Karnes
- Department of Pathology, Veterans Affairs Medical Center, Cincinnati, Ohio
| | - Priyank Shah
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Marian Dynis
- Apheresis Center, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Suzanne R Thibodeaux
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - George J Despotis
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri.,Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri
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12
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Hodulik KL, Root AG, Ledbetter LS, Onwuemene OA. Effects of therapeutic plasma exchange on anticoagulants in patients receiving therapeutic anticoagulation: a systematic review. Transfusion 2019; 59:1870-1879. [PMID: 30762882 DOI: 10.1111/trf.15191] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/04/2019] [Indexed: 12/12/2022]
Abstract
Therapeutic plasma exchange (TPE) removes coagulation proteins, but its impact on therapeutic anticoagulation is unknown. We performed a systematic review of the literature to determine the coagulation effects of TPE in patients receiving systemic anticoagulation. We searched MEDLINE, CINAHL, EMBASE, and Web of Science until June 2018 for studies combining controlled vocabulary and keywords related to therapeutic plasma exchange, plasmapheresis, anticoagulants, and therapy. The primary outcome was the effect of TPE on anti-Xa activity, activated partial thromboplastin time (aPTT), or international normalized ratio (INR). The secondary outcome was reports of post-TPE bleeding or thrombosis. A total of 1830 references were screened and eight studies identified. Our selected studies (five case reports and three case series) involved 23 patients and evaluated the effects of seven anticoagulants. Six studies of unfractionated heparin, low-molecular-weight heparins, and direct oral anticoagulants demonstrated an anti-Xa level decline. Two studies of unfractionated heparin and low-molecular-weight heparins showed an aPTT increase. One study of warfarin showed a post-TPE INR increase. Reports of post-TPE bleeding occurred in two patients and thrombosis in one. In patients receiving therapeutic anticoagulation, TPE is associated with anti-Xa activity decline and aPTT and INR increase. These coagulation changes do not appear to significantly increase bleeding or thrombotic risk. Our data suggest the need for prospective studies to investigate the true clinical impact of TPE on therapeutic anticoagulation.
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Affiliation(s)
- Kimberly L Hodulik
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Department of Pharmacy, Duke University Medical Center, Durham, North Carolina
| | - Adam G Root
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina
| | - Leila S Ledbetter
- Duke University Medical Center Library, Duke University Medical Center, Durham, North Carolina
| | - Oluwatoyosi A Onwuemene
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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13
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Zantek ND, Pagano MB, Rollins-Raval MA, Smith RE, Schmidt AE, Crane JE, Boral LI, Li Y, Svensson AM, Yamada C, Wu Y, Wong ECC. Hemostasis testing and therapeutic plasma exchange: Results of a practice survey. J Clin Apher 2018; 34:26-32. [DOI: 10.1002/jca.21666] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 07/31/2018] [Accepted: 09/03/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Nicole D. Zantek
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Monica B. Pagano
- Department of Laboratory Medicine; University of Washington; Seattle Washington
| | - Marian A. Rollins-Raval
- Department of Pathology and Laboratory Medicine; University of North Carolina; Chapel Hill North Carolina
| | - Roy E. Smith
- Hematology/Oncology Division; University of Pittsburgh Medical Center Presbyterian-Shadyside Hospital; Pittsburgh Pennsylvania
| | - Amy E. Schmidt
- Department of Pathology and Laboratory Medicine; University of Rochester Medical Center; Rochester New York
| | | | - Leonard I. Boral
- Department of Pathology and Laboratory Medicine; University of Kentucky; Lexington Kentucky
| | - Yanhua Li
- Department of Pathology and Laboratory Medicine; New York University; New York New York
| | | | - Chisa Yamada
- Department of Pathology; University of Michigan; Ann Arbor Michigan
| | | | - Edward C. C. Wong
- Department of Coagulation; Quest Diagnostics Nichols Institute; Virginia
- Departments of Pediatrics and Pathology; George Washington School of Medicine and Health Sciences; Washington DC
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14
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Vatazin AV, Zulkarnaev AB. The impact of therapeutic plasma exchange and double filtration plasmapheresis on hemostasis in renal transplant recipients. TERAPEVT ARKH 2018; 90:22-27. [DOI: 10.26442/terarkh201890622-27] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aim. To investigate the impact of double filtration plasmapheresis (DFPP) and therapeutic plasma exchange (TPE) on hemostasis in renal transplant recipients. Materials and methods. 54 renal transplant patients with an acute humoral rejection were treated with therapeutic apheresis methods: 24 patients with DFPP and 30 patients with TPE. In all patients was performed 3-4 session. We analyzed international normalized ratio (INR), activated partial thromboplastin time (APTT), fibrinogen concentration and platelet count just before and after each session, and after the course of all procedures. After TPE plasma replacement was performed with an equivalent volume of a fresh frozen plasma. After DFPP was performed 10-20% albumin solution. Results and discussion. After each DFPP session was occurred an increased INR and aPTT. After course of all DFPP procedures fibrinogen level decreased by 46%. It was associated with increase of APTT and INR by 35% and 32% respectively. Mainly it was associated with dose of the procedures (volume of plasma perfusion), but not with the plasma separator type. One patient noted hemorrhagic complication. After each TPE session level of fibrinogen concentration, INR and aPPT remained in the normal range, but there was a moderate reduction in platelet count, more pronounced than during DFPP. Hemorrhagic complications were not. Conclusion. Double cascade plasmapheresis and therapeutic plasma exchange generate preconditions for hemorrhagic complications such as increased aPTT and INR, reduce fibrinogen concentration. However, bleeding complications are rare. At the same time, during high volume DFPP should be careful when initially level of fibrinogen is low. In this case fibrinogen concentration should be controlled after the procedure for timely replenishment of its deficit.
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15
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Cid J, Carbassé G, Cid-Caballero M, López-Púa Y, Alba C, Perea D, Lozano M. The Barcelona Hospital Clínic therapeutic apheresis database. J Clin Apher 2017; 33:259-264. [DOI: 10.1002/jca.21587] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 08/03/2017] [Accepted: 09/06/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Joan Cid
- Apheresis Unit, Department of Hemotherapy and Hemostasis; ICMHO, IDIBAPS, Hospital Clínic, University of Barcelona; Barcelona Spain
| | - Gloria Carbassé
- Apheresis Unit, Department of Hemotherapy and Hemostasis; ICMHO, IDIBAPS, Hospital Clínic, University of Barcelona; Barcelona Spain
| | | | - Yolanda López-Púa
- Department of Preventive Medicine and Epidemiology; ICMiD, Hospital Clínic, University of Barcelona, ISGlobal; Barcelona Spain
| | - Cristina Alba
- Apheresis Unit, Department of Hemotherapy and Hemostasis; ICMHO, IDIBAPS, Hospital Clínic, University of Barcelona; Barcelona Spain
| | - Dolores Perea
- Apheresis Unit, Department of Hemotherapy and Hemostasis; ICMHO, IDIBAPS, Hospital Clínic, University of Barcelona; Barcelona Spain
| | - Miguel Lozano
- Apheresis Unit, Department of Hemotherapy and Hemostasis; ICMHO, IDIBAPS, Hospital Clínic, University of Barcelona; Barcelona Spain
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16
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Yamada C, Pipe SW, Zhao L, Leichtman AB, Samaniego M, Sung RS, Davenport RD. Coagulation status after therapeutic plasma exchange using citrate in kidney transplant recipients. Transfusion 2016; 56:3073-3080. [DOI: 10.1111/trf.13803] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/26/2016] [Accepted: 07/26/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Chisa Yamada
- Department of Pathology; University of Michigan; Ann Arbor Michigan
| | - Steven W. Pipe
- Department of Pediatrics/Pathology; University of Michigan; Ann Arbor Michigan
| | - Lili Zhao
- Department of Biostatistics; University of Michigan; Ann Arbor Michigan
| | - Alan B. Leichtman
- Department of Internal Medicine; University of Michigan; Ann Arbor Michigan
| | - Milagros Samaniego
- Department of Internal Medicine; University of Michigan; Ann Arbor Michigan
| | - Randall S. Sung
- Department of Surgery; University of Michigan; Ann Arbor Michigan
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