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Raina R, Nair N, Pelletier J, Nied M, Whitham T, Doshi K, Beck T, Dantes G, Sethi SK, Kim YH, Bunchman T, Alhasan K, Lima L, Guzzo I, Fuhrman D, Paden M. Concurrent use of continuous kidney replacement therapy during extracorporeal membrane oxygenation: what pediatric nephrologists need to know-PCRRT-ICONIC practice points. Pediatr Nephrol 2024:10.1007/s00467-024-06311-x. [PMID: 38386072 DOI: 10.1007/s00467-024-06311-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/15/2024] [Accepted: 01/27/2024] [Indexed: 02/23/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides temporary cardiorespiratory support for neonatal, pediatric, and adult patients when traditional management has failed. This lifesaving therapy has intrinsic risks, including the development of a robust inflammatory response, acute kidney injury (AKI), fluid overload (FO), and blood loss via consumption and coagulopathy. Continuous kidney replacement therapy (CKRT) has been proposed to reduce these side effects by mitigating the host inflammatory response and controlling FO, improving outcomes in patients requiring ECMO. The Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup and the International Collaboration of Nephrologists and Intensivists for Critical Care Children (ICONIC) met to highlight current practice standards for ECMO use within the pediatric population. This review discusses ECMO modalities, the pathophysiology of inflammation during an ECMO run, its adverse effects, various anticoagulation strategies, and the technical aspects and outcomes of implementing CKRT during ECMO in neonatal and pediatric populations. Consensus practice points and guidelines are summarized. ECMO should be utilized in patients with severe acute respiratory failure despite the use of conventional treatment modalities. The Extracorporeal Life Support Organization (ELSO) offers guidelines for ECMO initiation and management while maintaining a clinical registry of over 195,000 patients to assess outcomes and complications. Monitoring and preventing fluid overload during ECMO and CKRT are imperative to reduce mortality risk. Clinical evidence, resources, and experience of the nephrologist and healthcare team should guide the selection of ECMO circuit.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
| | - Nikhil Nair
- Case Western University School of Medicine, Cleveland, OH, USA
| | - Jonathan Pelletier
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA
- Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Matthew Nied
- Department of Internal Medicine, Case Western Reserve / University Hospitals, Cleveland, OH, USA
| | - Tarik Whitham
- Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Kush Doshi
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Tara Beck
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital, Pittsburgh, PA, USA
| | - Goeto Dantes
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Yap Hui Kim
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Timothy Bunchman
- Department of Pediatric Nephrology, Children's Hospital of Richmond, Richmond, VA, USA
| | - Kahild Alhasan
- Pediatric Nephrology, King Saud University, Riyadh, Saudi Arabia
| | - Lisa Lima
- Department of Pediatric Critical Care, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Dana Fuhrman
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital, Pittsburgh, PA, USA
| | - Matthew Paden
- Department of Pediatric Critical Care, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Turudic D, Dejanovic Bekic S, Mucavac L, Pavlovic M, Milosevic D, Bilic E. Case report: Autoimmune hemolytic anemia caused by warm and cold autoantibodies with complement activation-etiological and therapeutic issues. Front Pediatr 2023; 11:1217536. [PMID: 37794962 PMCID: PMC10546200 DOI: 10.3389/fped.2023.1217536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/01/2023] [Indexed: 10/06/2023] Open
Abstract
Introduction Research on mixed warm and cold autoantibodies in autoimmune hemolytic anemia (AIHA) targeting erythrocytes [red blood cells (RBCs)] and platelets is scarcely reported. Case presentation In this study, we present the case of a 5-year-old boy with positive direct [anti-IgG (1+), anti-IgG-C3d (3+)], and indirect antiglobulin (Coombs) tests. The RBCs were coated with polyspecific-positive, warm IgG autoantibodies alongside activated complement components. Plasma-containing immunoglobulin M (IgM) class autoantibodies were found in 1:64 titers with a wide temperature range of 4°C-37°C. The platelets were also coated with IgM autoantibodies. There was a reduction in the levels of the classical and alternative complement pathways, such as C3, C4, ADAMTS13 metalloprotease activity, factor H antigen, complement factor B antigen, and C1q antigen alongside the elevated sC5b-9 terminal complement complex. Hematuria and/or proteinuria, reduced diuresis, and elevated levels of serum creatinine were absent. The kidney ultrasound report was normal. A recent combination of Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infection was found. The first-line treatment consisted of intravenous methylprednisolone [4 mg/kg/body weight for the first 72 h (q12 h), followed by 2 mg/kg body weight for 21 consecutive days with a slow steroid reduction until plasmapheresis (PLEX)]. After the patient showed limited response to corticosteroid therapy, rituximab (375 mg/m2) was administered once a week (five doses in total), with vitamins B9 and B12. These strategies also showed limited (partial) therapeutic benefits. Therefore, the treatment was switched to PLEX (five cycles in total) and intravenous immunoglobulin (IVIg) (1 g/kg/5 days). This combination significantly improved RBC count and platelet levels, and C3 and C4 levels returned to normal. A follow-up of 2.5 years after treatment showed no sign of relapse. A genetic analysis revealed a rare heterozygous intronic variation (c.600-14C > T) and heterozygous Y402H polymorphism of the CFH gene. c.600-14C > T mutation was located near the 5' end of exon 6 in the gene encoding the complement C3 protein of unknown significance. We presumed that the complement regulators in our patient were sufficient to control complement activation and that complement blockade should be reserved only for devastating, life-threatening complement-related multiorgan failure. Conclusion We believe that EBV and CMV triggered AIHA, thus activating the complement cascade. Hence, we used corticosteroids, rituximab, vitamins B9 + B12, PLEX, and fresh frozen plasma (FFP) as treatment. Final remission was achieved with PLEX and FFP. However, an additional late effect of B12 rituximab and the disappearance of long-lived circulating plasma cells should not be completely ignored. Complement activation with a genetic background should be assessed in severe warm and cold hemolytic anemias caused by autoantibodies.
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Affiliation(s)
- Daniel Turudic
- Department of Pediatric Hematology and Oncology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Sara Dejanovic Bekic
- Department of Pediatric Hematology and Oncology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Lucija Mucavac
- Department of Pediatric Hematology and Oncology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Maja Pavlovic
- Department of Pediatric Hematology and Oncology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Danko Milosevic
- Croatian Academy of Medical Sciences, Zagreb, Croatia
- Department of Pediatrics, Zabok General Hospital and the Croatian Veterans Hospital, Zabok, Bračak, Croatia
| | - Ernest Bilic
- Department of Pediatric Hematology and Oncology, University Hospital Centre Zagreb, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
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Joffre J, Raia L, Urbina T, Bonny V, Gabarre P, Missri L, Baudel JL, Coppo P, Guidet B, Maury E, Ait-Oufella H. Reversible skin microvascular hyporeactivity in patients with immune-mediated thrombocytopenic thrombotic purpura. Crit Care 2023; 27:116. [PMID: 36944989 PMCID: PMC10028781 DOI: 10.1186/s13054-023-04405-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/15/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare disease characterized by arteriolar and capillary microthrombosis precipitating organ failure. However, the contribution of endothelial dysfunction on impaired microvascular blood flow in iTTP patients has been poorly explored. This pilot observational study aimed to explore endothelial-mediated vasoreactivity in iTTP patients at admission and its changes after plasma exchange therapy (PE). METHODS We conducted a prospective observational study in patients (> 18-year old) admitted in ICU for iTTP. Using laser Doppler flowmetry and acetylcholine (Ach) iontophoresis in the forearm, we recorded the skin microvascular blood flow and the endothelium-mediated vasoreactivity at admission and after PE. Demographics, biological, clinical courses, and outcomes were also collected. As a control group, we used a previously published cohort of young diabetic patients after correction of ketoacidosis. RESULTS Eighteen confirmed iTTP patients and 34 controls were included in the study, mainly female (72%) aged 43 ± 16-year-old. At admission, 55% had neurological abnormalities, 50% cardiac issues and 27.8% an acute kidney injury. Median platelet count was 19 G/mL [10-37]. Baseline microvascular blood flow was decreased in iTTP patients when compared to controls (5.97 ± 4.5 vs. 10.1 ± 6.3 PU, P = 0.03), associated with markedly impaired endothelial-mediated skin microvascular reactivity (AUC: 9627 ± 8122 vs. 16,475 ± 11,738, P = 0.03). Microvascular reactivity improved after the first PE session (AUC: 9627 ± 8122 vs 16,558 ± 10,699, P = 0.007, respectively, baseline and post-PE1) and much more after the second session (26,431 ± 23,181, P = 0.04 post-PE1 vs post-PE2). Hemolysis biomarkers (LDH and bilirubin) negatively correlated with skin microvascular flow and vasoreactivity. CONCLUSION We highlighted a marked yet reversible skin endothelium-mediated microvascular hyporeactivity in iTTP patients that could participate in organ injury pathophysiology.
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Affiliation(s)
- Jérémie Joffre
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
- Centre de Recherche Saint-Antoine Inserm UMR-S 938, Sorbonne University, 75012, Paris, France
| | - Lisa Raia
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Tomas Urbina
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Vincent Bonny
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Paul Gabarre
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Louai Missri
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Jean-Luc Baudel
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Paul Coppo
- Hematology Department, AP-HP, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
- French Reference Center for Thrombotic Microangiopathies (CNR-MAT), Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Bertrand Guidet
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Eric Maury
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Hafid Ait-Oufella
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France.
- Paris Cardiovascular Research Center, Inserm U970, University Paris Cité, Paris, France.
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Ginikopoulou E. Plasma exchange and COVID 19. Transfus Apher Sci 2022; 61:103598. [PMID: 36379843 PMCID: PMC9652706 DOI: 10.1016/j.transci.2022.103598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kiamos A, Boldig K, Reddy P. Refractory Thrombotic Thrombocytopenic Purpura to Therapeutic Plasma Exchange. Cureus 2022; 14:e29562. [PMID: 36312650 PMCID: PMC9595238 DOI: 10.7759/cureus.29562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 11/05/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare, potentially fatal hematologic disorder characterized by microangiopathic hemolytic anemia, thrombocytopenia, and varying signs of visceral ischemia secondary to microvascular thrombosis. TTP is caused by a severe deficiency of ADAMTS13, a protease enzyme responsible for cleaving von Willebrand-factor (vWF) multimers. First-line therapy with plasmapheresis has increased survival rates immensely; however, there are few reported cases that are refractory to standardized treatment. We describe two cases of refractory TTP successfully managed with the addition of caplacizumab, an anti-von Willebrand factor immunoglobulin fragment that inhibits the interaction of vWF multimers with platelets.
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Patidar GK, Land KJ, Vrielink H, Rahimi‐Levene N, Dann EJ, Al‐Humaidan H, Spitalnik SL, Dhiman Y, So ‐ Osman C, Hindawi SI. Understanding the role of therapeutic plasma exchange in COVID-19: preliminary guidance and practices. Vox Sang 2021; 116:798-807. [PMID: 33730761 PMCID: PMC8250601 DOI: 10.1111/vox.13067] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Cytokine release syndrome in COVID-19 is due to a pathological inflammatory response of raised cytokines. Removal of these cytokines by therapeutic plasma exchange (TPE) prior to end-organ damage may improve clinical outcomes. This manuscript is intended to serve as a preliminary guidance document for application of TPE in patients with severe COVID-19. MATERIAL AND METHODS The available literature pertaining to the role of TPE for treatment of COVID-19 patients was reviewed to guide optimal management. It included indication, contraindication, optimal timing of initiation and termination of TPE, vascular access and anticoagulants, numbers and mode of procedures, outcome measures and adverse events. RESULTS Out of a total of 78 articles, only 65 were directly related to the topic. From these 65, only 32 were acceptable as primary source, while 33 were used as supporting references. TPE in critically ill COVID-19 patients may be classified under ASFA category III grade 2B. The early initiation of TPE for 1-1·5 patient's plasma volume with fresh frozen plasma, or 4-5% albumin or COVID-19 convalescent plasma as replacement fluids before multiorgan failure, has better chances of recovery. The number of procedures can vary from three to nine depending on patient response. CONCLUSION TPE in COVID-19 patients may help by removing toxic cytokines, viral particles and/or by correcting coagulopathy or restoring endothelial membrane. Severity score (SOFA & APACHE II) and cytokine levels (IL-6, C-reactive protein) can be used to execute TPE therapy and to monitor response in COVID-19 patients.
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Affiliation(s)
- Gopal K. Patidar
- Department of Transfusion MedicineAll India Institute of Medical SciencesNew DelhiIndia
| | - Kevin J. Land
- Clinical ServicesVitalantScottsdaleAZUSA
- Department of PathologyUT Health Science Center San AntonioSan AntonioTXUSA
| | - Hans Vrielink
- Dept Unit Transfusion MedicineSanquin Blood BankAmsterdamthe Netherlands
| | - Naomi Rahimi‐Levene
- Blood BankShamir Medical CenterZerifinIsrael
- Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Eldad J. Dann
- Blood Bank and Aphaeresis InstituteRAMBAM Health Care CampusHematology and MedicineRappaport Faculty of MedicineTechnionHaifaIsrael
| | - Hind Al‐Humaidan
- Blood Bank (DS & TS)/Stem Cell Cord Blood Bank Pathology and Laboratory MedicineKing Faisal Specialist Hospital & Research CentreRiyadhKingdom of Saudi Arabia
| | | | - Yashaswi Dhiman
- Department of Transfusion MedicineAll India Institute of Medical SciencesNew DelhiIndia
| | - Cynthia So ‐ Osman
- Dept Unit Transfusion MedicineSanquin Blood BankAmsterdamthe Netherlands
- Dept. of HaematologyErasmus Medical CenterRotterdamthe Netherlands
| | - Salwa I. Hindawi
- Haematology & Transfusion MedicineFaculty of MedicineKing Abdulaziz UniversityJeddahSaudi Arabia
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Galstyan GM, Maschan AA, Klebanova EE, Kalinina II. [Treatment of thrombotic thrombocytopenic purpura]. TERAPEVT ARKH 2021; 93:826-829. [PMID: 36286735 DOI: 10.26442/00403660.2021.07.200914] [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: 07/21/2021] [Accepted: 07/21/2021] [Indexed: 11/22/2022]
Abstract
The review discusses approaches to treatment of congenital thrombotic thrombocytopenic purpura (TTP) or Upshaw-Schulman syndrome. In congenital TTP, plasma transfusions are sufficient. Such treatment options as plasma exchange, administration of clotting factor VIII concentrate, recombinant ADAMTS13, are also used. Separately discussed issues of management of patients with TTP during pregnancy, and pediatric patients with TTP.
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Affiliation(s)
| | - A A Maschan
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
| | | | - I I Kalinina
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
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Galstyan GM, Maschan AA, Klebanova EE, Kalinina II. [Treatment of thrombotic thrombocytopenic purpura]. TERAPEVT ARKH 2021; 93:736-745. [PMID: 36286842 DOI: 10.26442/00403660.2021.06.200894] [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: 07/10/2021] [Accepted: 07/10/2021] [Indexed: 11/22/2022]
Abstract
The review discusses approaches to treatment of acquired thrombotic thrombocytopenic purpuгa (aTTP). In patients with aTTP plasma exchanges, glucocorticosteroids allow to stop an acute attack of TTP, and use of rituximab allows to achieve remission. In recent years, caplacizumab has been used. Treatment options such as cyclosporin A, bortezomib, splenectomy, N-acetylcysteine, recombinant ADAMTS13 are also described. Separately discussed issues of management of patients with TTP during pregnancy, and pediatric patients with TTP.
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Affiliation(s)
| | - A A Maschan
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
| | | | - I I Kalinina
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
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Merli M, Alteri C, Colagrossi L, Perricone G, Chiappetta S, Travi G, Campisi D, Pugliano MT, Vecchi M, Orcese C, Rossini S, De Carlis L, Vismara C, Belli L, Perno CF, Puoti M. Mild Course of SARS-CoV-2 Infection in a Liver Transplant Recipient Undergoing Plasma Exchange and Defibrotide for Acute Graft Rejection. Transplantation 2021; 105:e22-e24. [PMID: 33492115 DOI: 10.1097/tp.0000000000003592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Marco Merli
- Division of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Claudia Alteri
- Department of Laboratory Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
| | - Luna Colagrossi
- Department of Laboratory Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
| | - Giovanni Perricone
- Division of Hepatology and Gastroenterology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefania Chiappetta
- Division of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giovanna Travi
- Division of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Daniela Campisi
- Department of Laboratory Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Teresa Pugliano
- Division of Immunohaematology and Transfusion Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marta Vecchi
- Division of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Carloandrea Orcese
- Division of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Silvano Rossini
- Division of Immunohaematology and Transfusion Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Luciano De Carlis
- Division of General and Transplantation Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Chiara Vismara
- Department of Laboratory Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Luca Belli
- Division of Hepatology and Gastroenterology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Carlo Federico Perno
- Department of Laboratory Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Oncology and Haemato-Oncology, University of Milan, Milan, Italy
| | - Massimo Puoti
- Division of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Tabibi S, Tabibi T, Conic RRZ, Banisaeed N, Streiff MB. Therapeutic Plasma Exchange: A potential Management Strategy for Critically Ill COVID-19 Patients. J Intensive Care Med 2020; 35:827-835. [PMID: 32666875 PMCID: PMC7391476 DOI: 10.1177/0885066620940259] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/27/2020] [Accepted: 06/17/2020] [Indexed: 01/08/2023]
Abstract
In the 5 months since initial reports of COVID-19 came to light, the death toll due to SARS-CoV-2 has rapidly increased. The morbidity and mortality of the infection varies based upon patient age, comorbid conditions, viral load, and the availability of effective treatments. Findings from limited autopsies, clinical observations, and laboratory data suggest that high cytokine levels and a procoagulant state can precipitate acute respiratory distress syndrome and multi-organ dysfunction syndrome in critically ill patients. To complicate matters, comorbidities may affect the response to medical treatments currently in use, all of which are still in trial phase. Therapeutic plasma exchange (TPE) merits consideration in the treatment of critically ill COVID-19 patients and is an avenue for clinical trials to pursue. If efficacious, faster recovery of patients may lead to shorter intensive care unit stays and less time on mechanical ventilation. Herein, we briefly discuss some of the various approaches currently being investigated for the treatment of SARS-CoV-2 with a focus on potential benefits of TPE for selected critically ill patients.
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Affiliation(s)
- Seena Tabibi
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tara Tabibi
- St. Louis University School of Medicine, St. Louis, MO, USA
| | | | - Nassim Banisaeed
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Michael B. Streiff
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Upadhya SR, Mahabala C, Kamat JG, Jeganathan J, Kumar S, Prabhu MV. Plasmapheresis in Sepsis-induced Thrombotic Microangiopathy: A Case Series. Indian J Crit Care Med 2020; 24:195-199. [PMID: 32435099 PMCID: PMC7225771 DOI: 10.5005/jp-journals-10071-23374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Cytokines and granulocyte elastase produced in sepsis cleave a disintegrin and metalloprotease with thrombospondin type I motif 13 (ADAMTS13) and deplete its levels. By this mechanism, sepsis results in microangiopathic hemolytic anemia (MAHA) with thrombocytopenia. Hence, the hypothesis is that plasmapheresis may help in sepsis-induced thrombotic microangiopathy (sTMA), by removing the factors responsible for low levels of ADAMTS13. In tropical countries like India, the contribution of sepsis to intensive care unit (ICU) mortality is high; and hence, it is essential to look out for newer modalities of sepsis treatment. There is abundant literature on the use of plasmapheresis in sepsis but data on its use in sTMA are limited, thus necessitating further research in this field. Case description This case series studies the outcomes of five patients admitted with sTMA in the ICU and attempts to evaluate the effectiveness of plasmapheresis in improving their outcomes. All patients diagnosed with sTMA and treated with plasmapheresis, between January 2016 and August 2018 at our tertiary care center, were selected for the study. The diagnosis of sepsis was based on sepsis-3 definition. Results Four different gram-negative organisms were found to have caused MAHA, with the commonest source being either urinary tract infection (UTI) or lower respiratory tract infection. Three of five patients required hemodialysis and two had disseminated intravascular coagulation (DIC). All five had good outcome and recovered well from the acute episode post plasmapheresis. Discussion In two of five patients, the initial smear was negative and hence the need for repeated examination of the peripheral blood smear should be kept in mind in cases of sTMAs. The median of the number of plasmapheresis sessions required in sTMA is six, which is lesser than that required for primary thrombotic thrombocytopenic purpura (TTP). Hence, the duration of central line placement and the risk of catheter-related complications are low. Based on the observations made in this case study, further exploratory studies are required to evaluate the efficacy of plasmapheresis in sTMA secondary to tropical infections. How to cite this article Upadhya SRS, Mahabala C, Kamat JG, Jeganathan J, Kumar S, Prabhu MV. Plasmapheresis in Sepsis-induced Thrombotic Microangiopathy: A Case Series. Indian J Crit Care Med 2020;24(3):195–199.
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Affiliation(s)
- Sushmita Rs Upadhya
- Department of Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Chakrapani Mahabala
- Department of Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Jayesh G Kamat
- Department of Anaesthesia, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Jayakumar Jeganathan
- Department of Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Sushanth Kumar
- Department of Nephrology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Mayur V Prabhu
- Department of Nephrology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
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Stratford LMI, Nahoor I, Dos Santos K, Dos Santos AA. A case of thrombotic microangiopathy of unknown aetiology, clinically presenting as an acute surgical abdomen. BMJ Case Rep 2019; 12:12/11/e230553. [PMID: 31780612 DOI: 10.1136/bcr-2019-230553] [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] [Indexed: 12/27/2022] Open
Abstract
A 48-year-old woman presented with severe abdominal pain, bilious vomiting and bloody diarrhoea for 1 day. On examination, she was haemodynamically unstable, febrile and clinically had an acute surgical abdomen. She had markedly raised inflammatory markers, neutrophils and deranged renal function. A CT abdominal scan revealed severe colitis and thickening throughout the length of the colon. The patient was stabilised and underwent emergency laparotomy resulting in total colectomy and end ileostomy formation. Postoperatively, she required several units of human albumin solution, red blood cell transfusions and octaplex (prothrombin complex) to prevent further bleeding. An inpatient haematology review revealed a hypocomplementaemia (C3/C4), low immunoglobulin (IgG, IgM, IgA) and peripheral blood films revealed schistocytosis indicating microangiopathic haemolytic anaemia. Bowel histology supported this, demonstrating circumferential lymphocytic phlebitis with thrombi and mucosal haemorrhage, necrosis and ulceration. The patient went on to suffer multiple ischaemic strokes before undergoing plasmapheresis, subsequent rehabilitation and making a successful recovery.
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Affiliation(s)
| | | | - Kataryna Dos Santos
- General Medicine Department, Russells Hall Hospital, Dudley, West Midlands, UK
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13
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Yetimakman AF, Kesici S, Bayrakci B. Plasma Filtration Versus Centrifugation in Pediatric Therapeutic Plasma Exchange: Should the Diagnosis Define the Method? †. Ther Apher Dial 2019; 24:85-89. [PMID: 31066994 DOI: 10.1111/1744-9987.12835] [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: 03/02/2019] [Revised: 04/21/2019] [Accepted: 05/06/2019] [Indexed: 11/27/2022]
Abstract
Therapeutic plasma exchange (TPE) is used for a variety of illnesses in critically ill pediatric patients. Although both centrifugation and filtration are known to be effective methods, to our knowledge, clinical results for TPE by these methods are not compared in pediatric patient populations. One hundred patients who had TPE for a variety of diagnoses were included in the study. In 55 patients plasma exchange was implemented by centrifugation and in 45, by filtration. These two groups were further divided into subgroups according to admittance diagnoses. The demographic information, admittance Pediatric Risk of Mortality scores, Pediatric Logistic Organ Dysfunction (PELOD) scores before beginning of therapy and PELOD at the end of therapy, durations of ventilatory support, pediatric intensive care unit and hospital stay, and outcomes were compared. Although the survival was significantly better in filtration group, it included more patients with neurologic diagnoses. Filtration group standard mortality rate was 0.6. In both groups, the PELOD scores after the termination of TPE were significantly decreased compared to that before beginning of TPE. Within thrombotic microangiopathy and hemophagocytic lymphohistiocytosis subgroups, median PELOD scores before treatment were higher in centrifugation patients but survival was similar with both methods. Both methods of TPE are alike in decreasing PELOD scores. In the filtration group, survival benefit of TPE is evident. In thrombotic microangiopathy patients, despite higher PELOD scores in the centrifugation group, survival is similar for both methods. These findings should be retested in randomized studies and the underlying physiology awaits to be uncovered.
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Affiliation(s)
- A Filiz Yetimakman
- Department of Pediatric Intensive Care Medicine, Hacettepe University, Ankara, Turkey
| | - Selman Kesici
- Department of Pediatric Intensive Care Medicine, Hacettepe University, Ankara, Turkey
| | - Benan Bayrakci
- Department of Pediatric Intensive Care Medicine, Hacettepe University, Ankara, Turkey
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14
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Chang JC. Sepsis and septic shock: endothelial molecular pathogenesis associated with vascular microthrombotic disease. Thromb J 2019; 17:10. [PMID: 31160889 PMCID: PMC6542012 DOI: 10.1186/s12959-019-0198-4] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 04/26/2019] [Indexed: 12/15/2022] Open
Abstract
In addition to protective “immune response”, sepsis is characterized by destructive “endothelial response” of the host, leading to endotheliopathy and its molecular dysfunction. Complement activation generates membrane attack complex (MAC). MAC causes channel formation to the cell membrane of pathogen, leading to death of microorganisms. In the host, MAC also may induce channel formation to innocent bystander endothelial cells (ECs) and ECs cannot be protected. This provokes endotheliopathy, which activates two independent molecular pathways: inflammatory and microthrombotic. Activated inflammatory pathway promotes the release of inflammatory cytokines and triggers inflammation. Activated microthrombotic pathway mediates platelet activation and exocytosis of unusually large von Willebrand factor multimers (ULVWF) from ECs and initiates microthrombogenesis. Excessively released ULVWF become anchored to ECs as long elongated strings and recruit activated platelets to assemble platelet-ULVWF complexes and form “microthrombi”. These microthrombi strings trigger disseminated intravascular microthrombosis (DIT), which is the underlying pathology of endotheliopathy-associated vascular microthrombotic disease (EA-VMTD). Sepsis-induced endotheliopathy promotes inflammation and DIT. Inflammation produces inflammatory response and DIT orchestrates consumptive thrombocytopenia, microangiopathic hemolytic anemia, and multiorgan dysfunction syndrome (MODS). Systemic inflammatory response syndrome (SIRS) is a combined phenotype of inflammation and endotheliopathy-associated (EA)-VMTD. Successful therapeutic design for sepsis can be achieved by counteracting the pathologic microthrombogenesis.
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Affiliation(s)
- Jae C Chang
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA USA
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15
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Abstract
: 'Disseminated intravascular coagulation (DIC)' occurs commonly in critical illnesses such as sepsis, trauma, cancer, and complications of surgery and pregnancy. Mortality is very high. The pathogenesis has been ascribed to tissue factor-initiated coagulation disorder, resulting in disseminated microblood clots that are made of platelets, plasma factors, fibrins, and blood cells. True DIC depletes coagulation factors and consumes platelets, and activates fibrinolysis. 'DIC' is assumed to orchestrate thrombocytopenia, microangiopathic hemolytic anemia and hypoxic multiorgan dysfunction syndrome, and causes hemorrhagic disorder due to depleted coagulation factors. In contrast, disseminated intravascular microthrombosis (DIT) occurs in thrombotic thrombocytopenic purpura (TTP) and TTP-like syndrome due to ADAMTS13 deficiency or insufficiency. The pathogenesis is due to formation of intravascular 'microthrombi' composed of complexes of platelets and unusually large von Willebrand factor multimers. Interestingly, DIT also occurs in the same critically ill patients as 'DIC' does. Following activation of complement system, the terminal complex C5b-9 causes endotheliopathy via channel formation to the endothelial cell membrane. Endotheliopathy activates microthrombotic pathway and initiates microthrombogenesis, leading to endotheliopathy-associated DIT. DIT results in TTP-like syndrome with hematologic phenotype of consumptive thrombocytopenia, microangiopathic hemolytic anemia, and multiorgan dysfunction syndrome. In reinterpretation of 'DIC', the true lesion is 'microthrombi' but not microblood clots. Thus, 'DIC' is endotheliopathy-associated DIT. This concept reconciles all the clinical features of 'DIC', and dramatically changes our understanding of pathophysiological mechanism in hemostasis and thrombosis. This new paradigm should assist the physician with correct diagnostic evaluation and treatment intervention.
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16
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Smeets NJL, Fijnheer R, Sebastian S, De Mast Q. Secondary thrombotic microangiopathy with severely reduced ADAMTS13 activity in a patient with Capnocytophaga canimorsus sepsis: a case report. Transfusion 2018; 58:2426-2429. [PMID: 30222856 DOI: 10.1111/trf.14829] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 03/25/2018] [Accepted: 03/30/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND The Gram-negative bacillus Capnocytophaga canimorsus may cause a severe illness resembling thrombotic thrombocytopenic purpura (TTP). The pathogenesis and optimal therapy of this secondary thrombotic microangiopathy (TMA) remain uncertain. CASE REPORT A 63-year-old Caucasian man was admitted with suspicion for TTP, but blood cultures grew C. canimorsus. Initial investigations revealed severe thrombocytopenia, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activity level of less than 1%, and strongly elevated D-dimer and lactate dehydrogenase levels. He made a full recovery with antibiotics and plasma infusion for 3 days. Plasmapheresis was not performed. Retrospective determination of serial ADAMTS13 activity levels revealed that ADAMTS13 activity had already increased to 25% at the start of plasma infusion. CONCLUSION This case highlights that a C. canimorsus sepsis may cause a secondary TMA with a severe ADAMTS13 deficiency. It also illustrates that the adjunctive role of plasma exchange or plasma infusion is doubtful as ADAMTS13 activity levels increased with antibiotics alone.
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Affiliation(s)
- Nori J L Smeets
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rob Fijnheer
- Department of Internal Medicine, Meander Medical Center, Amersfoort, the Netherlands.,Department of Clinical Chemistry and Haematology, University Medical Center, Utrecht, the Netherlands
| | - Silvie Sebastian
- Department of Clinical Chemistry and Haematology, University Medical Center, Utrecht, the Netherlands
| | - Quirijn De Mast
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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17
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Canter MO, Daniels J, Bridges BC. Adjunctive Therapies During Extracorporeal Membrane Oxygenation to Enhance Multiple Organ Support in Critically Ill Children. Front Pediatr 2018; 6:78. [PMID: 29670870 PMCID: PMC5893897 DOI: 10.3389/fped.2018.00078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/14/2018] [Indexed: 12/17/2022] Open
Abstract
Since the advent of extracorporeal membrane oxygenation (ECMO) over 40 years ago, there has been increasing interest in the use of the extracorporeal circuit as a platform for providing multiple organ support. In this review, we will examine the evidence for the use of continuous renal replacement therapy, therapeutic plasma exchange, leukopheresis, adsorptive therapies, and extracorporeal liver support in conjunction with ECMO.
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Affiliation(s)
- Marguerite Orsi Canter
- Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Jessica Daniels
- Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Brian C Bridges
- Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, United States
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18
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Singh K, Nadeem AJ, Doratotaj B. A rare case of thrombotic microangiopathy triggered by acute pancreatitis. BMJ Case Rep 2017; 2017:bcr-2016-218581. [PMID: 28512098 DOI: 10.1136/bcr-2016-218581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Thrombotic microangiopathy (TMA) occurring after acute pancreatitis is rarely described. Without prompt intervention, TMA can be, and often is, lethal, so prompt recognition is important. Here, we present a case of a 61-year-old woman with a history of alcohol misuse who presented with epigastric pain, nausea and vomiting after binge drinking. Elevated serum lipase and imaging were suggestive of acute-on-chronic pancreatitis. Although the patient's symptoms of acute pancreatitis subsided, her anaemia, thrombocytopenia and acute kidney injury worsened. A peripheral blood smear revealed schistocytes, prompting suspicion for TMA. Therapeutic plasma exchange (TPE) was promptly initiated and she completed 10 TPE sessions that improved her anaemia and serum creatinine and resolved the thrombocytopenia. Since TPE was effective and the ADAMTS13 assay revealed 55% activity in the absence of anti-ADAMTS13 IgG prior to initiation of therapy, a confident diagnosis of TMA caused by acute pancreatitis was made. There was no evidence of relapse 2 years later.
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Affiliation(s)
- Kevin Singh
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Ahmed Jamal Nadeem
- Department of Medicine, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Behzad Doratotaj
- Department of Haematology and Oncology, New York University School of Medicine, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
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19
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Warner NC, Vaughan LB, Wenzel RP. Human immunodeficiency virus associated thrombotic thrombocytopenic purpura, a clinical conundrum. J Clin Apher 2016; 32:567-570. [DOI: 10.1002/jca.21514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 09/02/2016] [Accepted: 09/19/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Nathaniel C. Warner
- Department of Internal Medicine; Virginia Commonwealth University; 5017 Caledonia Rd, Richmond Virginia 23225
| | - Leroy B. Vaughan
- Division of Infectious Diseases; Virginia Commonwealth University; Richmond Virginia
| | - Richard P. Wenzel
- Division of Infectious Diseases; Virginia Commonwealth University; Richmond Virginia
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20
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Alsaied T, Goldstein SL, Kaddourah A, Poynter SE. Thrombocytopenia-associated multi-organ failure caused by diabetic ketoacidosis. Pediatr Int 2016; 58:232-4. [PMID: 26712331 DOI: 10.1111/ped.12780] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 06/30/2015] [Accepted: 07/21/2015] [Indexed: 01/19/2023]
Abstract
Thrombocytopenia-associated multi-organ failure (TAMOF) is an increasingly reported entity in the pediatric intensive care unit. The clinical presentation is similar to thrombotic thrombocytopenic purpura, but with no evidence of hemolysis and no schistocytes on peripheral smear. We report a case of TAMOF induced by diabetic ketoacidosis and treated with therapeutic plasma exchange (TPE). Early diagnosis and initiation of TPE significantly decrease the morbidity associated with TAMOF.
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Affiliation(s)
- Tarek Alsaied
- Pediatric Residency Training Program, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ahmad Kaddourah
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sue E Poynter
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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21
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Ojeda-Uribe M, Merieau S, Guillon M, Aujoulat O, Hinschberger O, Eisenmann JC, Kenizou D, Debliquis A, Veyradier A, Chantrel F. Secondary thrombotic microangiopathy in two patients with Philadelphia-positive hematological malignancies treated with imatinib mesylate. J Oncol Pharm Pract 2015; 22:361-70. [PMID: 25591869 DOI: 10.1177/1078155214568580] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Drug-mediated thrombotic microangiopathy may cause life-threatening medical emergencies. Novel targeted therapies have dramatically changed the prognosis of a number of oncological diseases. Tyrosine kinase inhibitors of the Breakpoint Cluster Region-Abelson (BCR-ABL) oncoprotein are used in patients with chronic myeloid leukemia or Philadelphia chromosome-positive acute lymphoblastic leukemia. Imatinib mesylate, which was the first anti-BCR-ABL tyrosine kinase inhibitor, has demonstrated a high tolerance profile and efficacy in these patients for many years. Good results have also been observed in patients with gastrointestinal stromal tumors. In this study, we describe two patients with Philadelphia chromosome-positive hematological malignancies who presented with secondary thrombotic microangiopathy that was most likely linked to the use of imatinib. Other potential causes of thrombotic microangiopathy were discarded, and the predisposing role of some comorbidities and potential short or long-term drug-drug interactions was assessed. The clinical and biological data were more indicative of atypical secondary hemolytic uremic syndrome in one of the cases and of secondary thrombotic microangiopathy with renal and cardiac impairment in the other, which is also categorized as secondary hemolytic uremic syndrome. The outcome was favorable after imatinib discontinuation and the treatment of severe cardiac and renal failures.
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Affiliation(s)
- Mario Ojeda-Uribe
- Department of Hematology and Cellular Therapy Unit, Hôpital Emile Muller, Mulhouse, France Centre de Competences on Thrombotic Microangiopathies, Region Alsace, France
| | - Sylvain Merieau
- Laboratory of Hematology, Hôpital Emile Muller, Mulhouse, France
| | - Marie Guillon
- Laboratory of Hematology, Hôpital Emile Muller, Mulhouse, France
| | | | - Olivier Hinschberger
- Centre de Competences on Thrombotic Microangiopathies, Region Alsace, France Department of Internal Medicine, Hôpital Emile Muller, Mulhouse, France
| | - Jean-Claude Eisenmann
- Department of Hematology and Cellular Therapy Unit, Hôpital Emile Muller, Mulhouse, France
| | - David Kenizou
- Department of Cardiology, Hôpital Emile Muller, Mulhouse, France
| | - Agathe Debliquis
- Centre de Competences on Thrombotic Microangiopathies, Region Alsace, France Laboratory of Hematology, Hôpital Emile Muller, Mulhouse, France
| | - Agnès Veyradier
- Department of Biological Hematology, Assistance Publique-Hôpitaux de Paris, Hôpital Antoine Béclère, Université Paris, Clamart, France
| | - François Chantrel
- Centre de Competences on Thrombotic Microangiopathies, Region Alsace, France Department of Nephrology, Hôpital Emile Muller, Mulhouse, France
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22
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Owen L, Jones G, Despott EJ, Murray C, Atkinson C, Beal I, Webster DP. Fatal enteritis in a renal transplant patient with post-transplant thrombotic microangiopathy undergoing plasma exchange therapy. J Clin Virol 2014; 59:213-7. [PMID: 24495848 DOI: 10.1016/j.jcv.2014.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 01/04/2014] [Accepted: 01/06/2014] [Indexed: 11/20/2022]
Affiliation(s)
- Leah Owen
- Watford General Hospital, Vicarage Road, Watford, Hertfordshire, WD18 0HB, United Kingdom.
| | - Gareth Jones
- Royal Free Hospital, Pond Street, London NW3 2QG, United Kingdom.
| | - Edward J Despott
- Royal Free Unit for Endoscopy & Centre for Gastroenterology, UCL Institute for Liver & Digestive Health, 8th Floor South Offices, Royal Free Hospital and University College London, Pond Street, London NW3 2QG, United Kingdom.
| | - Claire Murray
- Department of Cellular Pathology, Royal Free Hospital NHS Trust, Pond Street, London, NW3 2QG, United Kingdom.
| | - Claire Atkinson
- Department of Virology, Royal Free Hospital and University College London, Pond Street, London NW3 2QG, United Kingdom.
| | - Isobel Beal
- Royal Free Hospital, Pond Street, London NW3 2QG, United Kingdom.
| | - Daniel P Webster
- Department of Virology, Royal Free Hospital and University College London, Pond Street, London NW3 2QG, United Kingdom.
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23
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Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580-637. [PMID: 23353941 DOI: 10.1097/ccm.0b013e31827e83af] [Citation(s) in RCA: 3898] [Impact Index Per Article: 354.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. DESIGN A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations. RESULTS Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). CONCLUSIONS Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.
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24
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Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb S, Beale RJ, Vincent JL, Moreno R. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013; 39:165-228. [PMID: 23361625 PMCID: PMC7095153 DOI: 10.1007/s00134-012-2769-8] [Citation(s) in RCA: 3088] [Impact Index Per Article: 280.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 11/12/2012] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. DESIGN A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. RESULTS Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO (2)/FiO (2) ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a PaO (2)/FI O (2) <150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are >180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5-10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). CONCLUSIONS Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.
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Thrombotic microangiopathy in sickle cell disease crisis. Ann Hematol 2012; 92:509-15. [DOI: 10.1007/s00277-012-1647-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Accepted: 11/26/2012] [Indexed: 10/27/2022]
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Peña-Irún A, González-Santamaría A. Tratamiento con infusión de plasma en un paciente afecto de síndrome hemolítico urémico. Rev Clin Esp 2012; 212:270-1. [DOI: 10.1016/j.rce.2012.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 02/13/2012] [Indexed: 11/30/2022]
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