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Gubensek J. The role of apheresis and insulin therapy in hypertriglyceridemic acute pancreatitis-a concise review. BMC Gastroenterol 2023; 23:341. [PMID: 37789261 PMCID: PMC10546782 DOI: 10.1186/s12876-023-02957-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/12/2023] [Indexed: 10/05/2023] Open
Abstract
Severe hypertriglyceridemia (HTG) is the third most common cause of acute pancreatitis (AP) and is involved in its pathogenesis. Chylomicrons increase blood viscosity and induce ischemia, while free fatty acids induce inflammation and distant organ damage. Conservative treatment options include fasting and insulin; limited evidence shows their comparable efficacy. Plasma exchange might provide more rapid lowering of triglycerides and amelioration of systemic effects of severe AP. Available data from controlled studies show only moderately faster lowering of triglycerides with apheresis (about 70% vs. 50% with conservative treatment within 24 h) and limited data from non-randomized studies show no improvement in clinical outcomes. New evidence is expected soon from ongoing large randomized trials. Until then, insulin may be used in mild HTG-AP and plasma exchange should be considered only in severe HTG-AP, especially if the decline of triglycerides with conservative treatment is slow, and in HTG-AP during pregnancy.
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Affiliation(s)
- Jakob Gubensek
- Department of Nephrology, University Medical Center Ljubljana, Zaloska cesta 7, 1000, Ljubljana, Slovenia.
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
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David S, Russell L, Castro P, van de Louw A, Zafrani L, Pirani T, Nielsen ND, Mariotte E, Ferreyro BL, Kielstein JT, Montini L, Brignier AC, Kochanek M, Cid J, Robba C, Martin-Loeches I, Ostermann M, Juffermans NP. Research priorities for therapeutic plasma exchange in critically ill patients. Intensive Care Med Exp 2023; 11:26. [PMID: 37150798 PMCID: PMC10164453 DOI: 10.1186/s40635-023-00510-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/10/2023] [Indexed: 05/09/2023] Open
Abstract
Therapeutic plasma exchange (TPE) is a therapeutic intervention that separates plasma from blood cells to remove pathological factors or to replenish deficient factors. The use of TPE is increasing over the last decades. However, despite a good theoretical rationale and biological plausibility for TPE as a therapy for numerous diseases or syndromes associated with critical illness, TPE in the intensive care unit (ICU) setting has not been studied extensively. A group of eighteen experts around the globe from different clinical backgrounds used a modified Delphi method to phrase key research questions related to "TPE in the critically ill patient". These questions focused on: (1) the pathophysiological role of the removal and replacement process, (2) optimal timing of treatment, (3) dosing and treatment regimes, (4) risk-benefit assumptions and (5) novel indications in need of exploration. For all five topics, the current understanding as well as gaps in knowledge and future directions were assessed. The content should stimulate future research in the field and novel clinical applications.
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Affiliation(s)
- Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland.
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany.
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Andry van de Louw
- Medical Intensive Care Unit, Penn State Health Hershey Medical Center, Hershey, PA, USA
| | - Lara Zafrani
- Medical Intensive Care Unit, Saint-Louis Hospital, AP-HP, University of Paris Cité, Paris, France
| | - Tasneem Pirani
- King's College Hospital, General and Liver Intensive Care, London, UK
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine & Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Eric Mariotte
- Medical Intensive Care Unit, Saint-Louis Hospital, AP-HP, University of Paris Cité, Paris, France
| | - Bruno L Ferreyro
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada
| | - Jan T Kielstein
- Medical Clinic V, Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Brunswick, Germany
| | - Luca Montini
- Department of Intensive Care Medicine and Anesthesiology, "Fondazione Policlinico Universitario Agostino Gemelli IRCCS" Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anne C Brignier
- Apheresis Unit, Saint-Louis Hospital, AP-HP, University of Paris Cite, Paris, France
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO), University of Cologne, Cologne, Germany
| | - Joan Cid
- Apheresis and Cellular Therapy Unit, Department of Hemotherapy and Hemostasis, ICMHO, Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Chiara Robba
- IRCCS per Oncologia e Neuroscienze, Genoa, Italy
- Dipartimento di Scienze Chirurgiche Diagnostiche ed Integrate, Universita' di Genova, Genoa, Italy
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, D08 NHY1, Ireland
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin, D02 PN91, Ireland
- Institut D'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Hospital Clinic, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - Marlies Ostermann
- Department of Intensive Care, Guy's & St Thomas' Hospital, King's College London, London, UK
| | - Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
- Laboratory of Translational Intensive Care, Erasmus MC, Rotterdam, The Netherlands
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3
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Chen LN, Montemayor-Garcia C, West-Mitchell KA, Cantilena CC. Increased serum pro-B-type natriuretic peptide in hematopoietic progenitor cell donors stimulated with G-CSF. J Clin Apher 2022; 37:354-359. [PMID: 35301751 PMCID: PMC9378357 DOI: 10.1002/jca.21979] [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: 10/15/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 11/07/2022]
Abstract
Hematopoietic stem cells (HPCs) donors mobilized by granulocyte-colony-stimulating factor (G-CSF) can develop various signs and symptoms. proBNP (pro-B-type natriuretic peptide) is a serum marker of heart failure. A donor who developed severe adverse reactions after G-CSF mobilization was found to have high serum proBNP levels. We followed additional donors who received identical mobilization regimen to investigate the prevalence of this phenomenon. Eighteen healthy donors underwent a mobilization regimen of 10 μg/Kg G-CSF daily for 5 days prior to allogeneic HPC collection using Spectra Optia between January 2016 and February 2017 were included in this study. Serum proBNP levels were measured before and after G-CSF stimulation and immediately after apheresis. Apheresis collection parameters and other laboratory results were also reviewed. The majority of donors (86.7%) had post-G-CSF elevation of serum proBNP. Seven of those had elevated proBNP above upper normal range (124 pg/ml). The subgroup of donors with normal proBNP is younger (median age of 37 vs 42 years), with majority being male (90.9% vs 28.6%) and with smaller processed blood volume (2.2 vs 3 × total blood volume). This case series demonstrates an increase of serum proBNP can be common in HPC donors stimulated with 5 days of 10 mcg/kg G-CSF. This is an adverse reaction that has not been described before. The temporary elevation of proBNP in these donors is not associated with ventricular dysfunction of the heart. The risk factors for marked elevation of proBNP post-G-CSF should be further investigated.
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Affiliation(s)
- Leonard N Chen
- Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | | | | | - Cathy C Cantilena
- Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
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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] [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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Boser M, Kielstein JT. [Role of plasmapheresis and immunoadsorption in salvage therapy of rheumatological diseases]. Z Rheumatol 2017; 75:964-972. [PMID: 27807630 DOI: 10.1007/s00393-016-0219-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Many rheumatological diseases are either caused by specific known proteins, such as antibodies or mediated by a plethora of cytokines. Both the unspecific immunosuppressive therapy and the specific action of biologics usually require time to be effective; therefore, extracorporeal forms of treatment are increasingly being employed in severe forms of rheumatological diseases as well as in patients who cannot tolerate pharmacological treatment or where the risk of pharmacological treatment may outweigh the potential benefits. Therapeutic plasma exchange (TPE) removes not only pathogenic substances, such as autoantibodies, lipoproteins and circulating immune complexes from the plasma but also cytokines. The removed plasma that is discarded has to be substituted by blood products, e.g. human albumin or fresh frozen plasma. Fresh frozen plasma is always used when missing plasma components must be replenished, such as ADAMTS-13 in thrombotic thrombocytopenic purpura (TTP). The separated plasma can be further processed by pumping into a hollow fiber filter (cut-off of ~700 kD) and in this way low-density lipoprotein cholesterol and IgM can be eliminated. This treatment mode, called cascade filtration is used to treat diseases, such as Waldenström's macroglobulinemia and cryoglobulinemia. A specific way to remove antibodies is by immunoadsorption in which the antibodies are specifically removed by an adsorber. For this procedure there is no need to substitute blood products. This review article describes the principles of the two different treatment methods, the advantages and disadvantages and also summarizes the current evidence for their use in rheumatological diseases.
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Affiliation(s)
- M Boser
- Medizinische Klinik V, Städtisches Klinikum Braunschweig, Salzdahlumer Str. 90, 38126, Braunschweig, Deutschland
| | - J T Kielstein
- Medizinische Klinik V, Städtisches Klinikum Braunschweig, Salzdahlumer Str. 90, 38126, Braunschweig, Deutschland.
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Kes P, Janssens ME, Bašić‐Jukić N, Kljak M. A randomized crossover study comparing membrane and centrifugal therapeutic plasma exchange procedures. Transfusion 2016; 56:3065-3072. [DOI: 10.1111/trf.13850] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 07/28/2016] [Accepted: 08/01/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Petar Kes
- Department of Nephrology, Arterial Hypertension, Dialysis and Kidney TransplantationUniversity Hospital Centre Zagreb, and Faculty of Medicine, University of ZagrebZagreb Croatia
| | | | - Nikolina Bašić‐Jukić
- Department of Nephrology, Arterial Hypertension, Dialysis and Kidney TransplantationUniversity Hospital Centre Zagreb, and Faculty of Medicine, University of ZagrebZagreb Croatia
| | - Milića Kljak
- Department of Nephrology, Arterial Hypertension, Dialysis and Kidney TransplantationUniversity Hospital Centre Zagreb, and Faculty of Medicine, University of ZagrebZagreb Croatia
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Hafer C, Golla P, Gericke M, Eden G, Beutel G, Schmidt JJ, Schmidt BMW, De Reys S, Kielstein JT. Membrane versus centrifuge-based therapeutic plasma exchange: a randomized prospective crossover study. Int Urol Nephrol 2016; 48:133-8. [PMID: 26531062 PMCID: PMC5360823 DOI: 10.1007/s11255-015-1137-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 10/09/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) is either performed using a highly permeable filter with standard multifunctional renal replacement equipment (mTPE) or a centrifugation device (cTPE). Although both techniques are well established in clinical practice, performance of these two modes of TPE was never compared in a prospective randomized fashion. Thus we aimed to compare two commercially available therapeutic apheresis systems: mTPE (Octonova with Plasmaflo filter) and cTPE (Spectra Optia apheresis system). METHODS Twenty-one patients (age 51.6 ± 13.5 years; 10 F/11 M; BMI 25.1 ± 5.0 kg/m(2)) were enrolled in this randomized, prospective, paired, crossover study performed in the Hannover Medical School, Germany. First treatment (either mTPE or cTPE) was chosen by an online randomization list. The primary endpoints were plasma removal efficiency with 1.2× of the total plasma volume exchanged. Secondary endpoints were total amount of plasma substances removed, such as IgG and fibrinogen. Further, the treatment effect on platelet count and complications were evaluated. RESULTS Despite a comparable volume of the processed plasma, mTPE treatment time was 10.5 % longer than cTPE treatment time (p < 0.05), resulting in a 10 % lower plasma removal rate of the mTPE treatment. Both treatments were comparable in terms of decrease in median (IQR) IgG [pre-mTPE 5.34 (3.48-8.37), post-mTPE 1.96 (1.43-2.84) g/L; pre-cTPE 5.88 (3.42-8.84), post-cTPE 1.89 (1.21-3.52) g/L]. Also the median (IQR) amount of IgG removed in mTPE [13.14 (7.42-16.10) g] was not different from the cTPE treatment [9.30 (6.26-15.69) g]. This was also true for IgM removal. Platelet loss during mTPE was nearly twice as much as with cTPE (15 ± 9 versus 7 ± 9 %, p < 0.05). CONCLUSION Although the centrifugal procedures were conducted using flow rates that could easily be obtained using peripheral access, plasma removal efficiency was significantly higher and treatment time was significantly lower in cTPE as compared to mTPE. Despite this lower treatment time, the decline in markers of procedure efficacy was comparable. Especially in centers performing many procedures per year, cTPE in contrast to mTPE can reduce treatment time without compromising treatment efficacy.
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Affiliation(s)
- Carsten Hafer
- Department of Nephrology and Hypertension, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Paulina Golla
- Department of Nephrology and Hypertension, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | | | - Gabriele Eden
- Department of Nephrology and Hypertension, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
- Medical Clinic V, Teaching Hospital Braunschweig, Braunschweig, Germany
| | - Gernot Beutel
- Department of Haematology, Oncology and Stem Cell Transplantation, Medical School Hannover, Hannover, Germany
| | - Julius J Schmidt
- Department of Nephrology and Hypertension, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Bernhard M W Schmidt
- Department of Nephrology and Hypertension, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | | | - Jan T Kielstein
- Department of Nephrology and Hypertension, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
- Medical Clinic V, Teaching Hospital Braunschweig, Braunschweig, Germany.
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Schmidt JJ, Jahn J, Golla P, Hafer C, Kielstein JT, Kielstein H. Effect of therapeutic plasma exchange on plasma levels and total removal of adipokines and inflammatory markers. BMC OBESITY 2015; 2:37. [PMID: 26425347 PMCID: PMC4588244 DOI: 10.1186/s40608-015-0067-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 09/12/2015] [Indexed: 12/21/2022]
Abstract
Background Aside from well-established inflammatory mediators adipokines have recently been found to play an important role in a variety of immunologic diseases. Therapeutic plasma exchange (TPE) is an established treatment modality for the acute removal of pathophysiological relevant disease mediators. The aim of this study was to determine adipokine removal during TPE therapy. Methods 21 Caucasian patients (10 females, 11 males) with an indication for TPE using albumin as exchange fluid received two consecutive TPE sessions. Blood samples for measurement of resistin, leptin, sICAM-1, sCD40L, MCP-1, and sTNF-R were drawn before and at the end of each TPE session. Samples from the total removed plasma were collected at the end of every treatment. Results We found a significant reduction in pre- vs. post-TPE plasma concentrations for sICAM-1 (517 ± 246 vs. 260 ± 159 ng/ml, p < 0.0001), sTNF-R (8.1 ± 6.4 vs. 5.7 ± 3.9 ng/ml, p < 0.05), and resistin plasma levels (14.3 ± 6.9 vs. 9.5 ± 4.7 ng/ml, p < 0.001). Solely sICAM-1 reduction persisted for 25 ± 5 h between the first and second TPE treatment, while the other investigated mediators increased to baseline levels. Substantial amounts of all measured mediators could be recovered from the removed plasma. Conclusions TPE provides a persistent reduction in sICAM-1 levels and temporarily affects several adipokine and cytokine plasma levels. Our findings are of importance not only for the interpretation of blood levels of cytokines in patients undergoing TPE but provide solid evidence that TPE markedly decreases sICAM-1.
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Affiliation(s)
- Julius J Schmidt
- Department of Internal Medicine, Division of Nephrology and Hypertension, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Janine Jahn
- Department of Anatomy and Cell Biology, Faculty of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Paulina Golla
- Department of Internal Medicine, Division of Nephrology and Hypertension, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Carsten Hafer
- Department of Internal Medicine, Division of Nephrology and Hypertension, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Jan T Kielstein
- Department of Internal Medicine, Division of Nephrology and Hypertension, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Heike Kielstein
- Department of Anatomy and Cell Biology, Faculty of Medicine, Martin Luther University Halle-Wittenberg, Halle, Germany
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Benhamou Y, Boelle PY, Baudin B, Ederhy S, Gras J, Galicier L, Azoulay E, Provôt F, Maury E, Pène F, Mira JP, Wynckel A, Presne C, Poullin P, Halimi JM, Delmas Y, Kanouni T, Seguin A, Mousson C, Servais A, Bordessoule D, Perez P, Hamidou M, Cohen A, Veyradier A, Coppo P. Cardiac troponin-I on diagnosis predicts early death and refractoriness in acquired thrombotic thrombocytopenic purpura. Experience of the French Thrombotic Microangiopathies Reference Center. J Thromb Haemost 2015; 13:293-302. [PMID: 25403270 DOI: 10.1111/jth.12790] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Indexed: 08/31/2023]
Abstract
BACKGROUND Cardiac involvement is a major cause of mortality in patients with thrombotic thrombocytopenic purpura (TTP). However, diagnosis remains underestimated and delayed, owing to subclinical injuries. Cardiac troponin-I measurement (cTnI) on admission could improve the early diagnosis of cardiac involvement and have prognostic value. OBJECTIVES To assess the predictive value of cTnI in patients with TTP for death or refractoriness. PATIENTS/METHODS The study involved a prospective cohort of adult TTP patients with acquired severe ADAMTS-13 deficiency (< 10%) and included in the registry of the French Reference Center for Thrombotic Microangiopathies. Centralized cTnI measurements were performed on frozen serum on admission. RESULTS Between January 2003 and December 2011, 133 patients with TTP (mean age, 48 ± 17 years) had available cTnI measurements on admission. Thirty-two patients (24%) had clinical and/or electrocardiogram features. Nineteen (14.3%) had cardiac symptoms, mainly congestive heart failure and myocardial infarction. Electrocardiogram changes, mainly repolarization disorders, were present in 13 cases. An increased cTnI level (> 0.1 μg L(-1) ) was present in 78 patients (59%), of whom 46 (59%) had no clinical cardiac involvement. The main outcomes were death (25%) and refractoriness (17%). Age (P = 0.02) and cTnI level (P = 0.002) showed the greatest impact on survival. A cTnI level of > 0.25 μg L(-1) was the only independent factor in predicting death (odds ratio [OR] 2.87; 95% confidence interval [CI] 1.13-7.22; P = 0.024) and/or refractoriness (OR 3.03; 95% CI 1.27-7.3; P = 0.01). CONCLUSIONS A CTnI level of > 0.25 μg L(-1) at presentation in patients with TTP appears to be an independent factor associated with a three-fold increase in the risk of death or refractoriness. Therefore, cTnI level should be considered as a prognostic indicator in patients diagnosed with TTP.
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Affiliation(s)
- Y Benhamou
- Service de Médecine Interne, CHU Charles Nicolle, Rouen, France; Inserm U1096, Rouen, France; Centre de Référence des Microangiopathies Thrombotiques, Hôpital Saint-Antoine, AP-HP, Paris, France
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