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Vural E, Elverdi T, Salihoğlu A, Ar MC, Öngören Ş, Başlar Z, Soysal T, Eşkazan AE. Complications of therapeutic plasma exchange: A retrospective, single-center study of 2505 procedures performed in 338 patients over 15 years. Ther Apher Dial 2024. [PMID: 38924694 DOI: 10.1111/1744-9987.14173] [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: 12/22/2023] [Revised: 05/18/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Therapeutic plasma exchange (TPE) may involve complications. We aimed to review the demographic data, indications, technical information, and complications. METHODS Data for TPE procedures (TPEPs) performed between 2004 and 2018 were retrospectively. RESULTS This study covered 2505 TPEPs performed on 338 patients; 55% of them were female (n = 186), and the median age was 36 years (range, 11-93 years). Most TPEPs were administered for hematological (40.6%) indications. The incidence of complications on the first procedure was 3.2% (n = 80); only 16 procedures (0.6%) were failed. The complication incidence was 19.8% (n = 497), with 789 total complications. Most of the complications were patient-related (90.4%), and the most of them were urticaria (29.1%), occlusion (3.2%), and faulty systems (1.01%), respectively. The use of only fresh frozen plasma as replacement fluid caused a higher complication rate (22.1%, p < 0.01). CONCLUSION The number of TPEPs is increasing every day. Hematologic indications for TPE and the use of fresh frozen plasma may increase the risk of complications.
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Affiliation(s)
- Ece Vural
- Department of Hematology, Sivas State Hospital, Sivas, Turkey
| | - Tuğrul Elverdi
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Ayşe Salihoğlu
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Muhlis Cem Ar
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
- Therapeutic Apheresis Unit, Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Şeniz Öngören
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Zafer Başlar
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Teoman Soysal
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Ahmet Emre Eşkazan
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
- Therapeutic Apheresis Unit, Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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Tonev DG, Momchilova AB. Therapeutic Plasma Exchange in Certain Immune-Mediated Neurological Disorders: Focus on a Novel Nanomembrane-Based Technology. Biomedicines 2023; 11:biomedicines11020328. [PMID: 36830870 PMCID: PMC9953422 DOI: 10.3390/biomedicines11020328] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 01/26/2023] Open
Abstract
Therapeutic plasma exchange (TPE) is an efficient extracorporeal blood purification technique to remove circulating autoantibodies and other pathogenic substances. Its mechanism of action in immune-mediated neurological disorders includes immediate intravascular reduction of autoantibody concentration, pulsed induction of antibody redistribution, and subsequent immunomodulatory changes. Conventional TPE with 1 to 1.5 total plasma volume (TPV) exchange is a well-established treatment in Guillain-Barre Syndrome, Chronic Inflammatory Demyelinating Polyradiculoneuropathy, Neuromyelitis Optica Spectrum Disorder, Myasthenia Gravis and Multiple Sclerosis. There is insufficient evidence for the efficacy of so-called low volume plasma exchange (LVPE) (<1 TPV exchange) implemented either by the conventional or by a novel nanomembrane-based TPE in these neurological conditions, including their impact on conductivity and neuroregenerative recovery. In this narrative review, we focus on the role of nanomembrane-based technology as an alternative LVPE treatment option in these neurological conditions. Nanomembrane-based technology is a promising type of TPE, which seems to share the basic advantages of the conventional one, but probably with fewer adverse effects. It could play a valuable role in patient management by ameliorating neurological symptoms, improving disability, and reducing oxidative stress in a cost-effective way. Further research is needed to identify which patients benefit most from this novel TPE technology.
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Affiliation(s)
- Dimitar G. Tonev
- Department of Anesthesiology and Intensive Care, Medical University of Sofia, University Hospital “Tzaritza Yoanna—ISUL”, 1527 Sofia, Bulgaria
- Correspondence:
| | - Albena B. Momchilova
- Institute of Biophysics and Biomedical Engineering, Bulgarian Academy of Science, 1113 Sofia, Bulgaria
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3
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Liou YT, Wei JCC, Hu KC, Hung YM, Chou MC, Chang R. Risk of subsequent atrial fibrillation in patients with myasthenia gravis: A population-based cohort study. Medicine (Baltimore) 2021; 100:e26008. [PMID: 34011098 PMCID: PMC8137031 DOI: 10.1097/md.0000000000026008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 05/01/2021] [Indexed: 01/05/2023] Open
Abstract
The purpose of this study was to explore the association between myasthenia gravis (MG) and the risk of atrial fibrillation (AF) in an Asian population. The risk was analyzed in a cohort of 5528 patients with history of MG and 5528 individuals without MG using a hospitalization claim dataset. Both groups were matched by age, sex, index year and baseline comorbidities as an original analysis. A Cox proportional hazard model was used to estimate the hazard ratio and 95% confidence interval of AF after adjusting for demographic and relevant clinical covariates. The adjusted hazard ratio of the MG group compared with that of the non-MG group was 1.03 (95% confidence interval, 0.76-1.38) for AF. A stratified analysis showed that compared with the propensity score matched non-MG group, there was no increased risk of developing AF based on age categories, gender, or comorbidities. Different time follow-up periods results showed no increased risk of AF compared with the non-MG group. Overall, in the Taiwanese cohort, MG is not associated with an increased risk of AF.
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Affiliation(s)
- Yaw-Tzeng Liou
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
| | - James Cheng-Chung Wei
- Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital
- Institute of Medicine, Chung Shan Medical University
- Graduate Institute of Integrated Medicine, China Medical University
| | - Kai-Chieh Hu
- Management office for Health Data, China Medical University Hospital, Taichung
| | - Yao-Min Hung
- Department of Internal Medicine, Kaohsiung Municipal United Hospital, Kaohsiung
- College of Health and Nursing, Meiho University
| | - Mei-Chia Chou
- Department of Recreation and Sports Management, Tajen University
- Department of Physical Medicine and Rehabilitation, Kaohsiung Veterans General Hospital, Pingtung Branch, Pingtung County, Taiwan
| | - Renin Chang
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
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4
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Zheng L, Zhang D, Cao W, Song WC, Zheng XL. Synergistic effects of ADAMTS13 deficiency and complement activation in pathogenesis of thrombotic microangiopathy. Blood 2019; 134:1095-1105. [PMID: 31409673 PMCID: PMC6764266 DOI: 10.1182/blood.2019001040] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/02/2019] [Indexed: 12/13/2022] Open
Abstract
Severe deficiency of plasma ADAMTS13 activity is the primary cause of thrombotic thrombocytopenic purpura (TTP) whereas overwhelming activation of complement via an alternative pathway results in atypical hemolytic uremic syndrome (aHUS), the prototypes of thrombotic microangiopathy (TMA). However, clinical and pathogenic distinctions between TTP and aHUS are often quite challenging. Clinical reports have suggested that complement activation may play a role in the development of TTP, which is caused by severe deficiency of plasma ADAMTS13 activity. However, the experimental evidence to support this hypothesis is still lacking. Here, we show that mice with either Adamts13 -/- or a heterozygous mutation of complement factor H (cfh) at amino acid residue of 1206 (ie, cfh W/R ) alone remain asymptomatic despite the presence of occasional microvascular thrombi in various organ tissues. However, mice carrying both Adamts13 -/- and cfh W/R exhibit thrombocytopenia, low haptoglobin, increased fragmentation of erythrocytes in peripheral blood smear, increased plasma levels of lactate dehydrogenase activity, blood urea nitrogen, and creatinine, as well as an increased mortality rate, consistent with the development of TMA. Moreover, mice with a homozygous mutation of cfh (ie, cfh R/R ) with or without Adamts13 -/- developed severe TMA. The mortality rate in mice with Adamts13 -/- cfh R/R was significantly higher than that in mice with cfh R/R alone. Histological and immunohistochemical analyses demonstrated the presence of disseminated platelet-rich thrombi in terminal arterioles and capillaries of major organ tissues in these mice that were either euthanized or died. Together, our results support a synergistic effect of severe ADAMTS13 deficiency and complement activation in pathogenesis of TMA in mice.
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Affiliation(s)
- Liang Zheng
- Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL; and
| | - Di Zhang
- Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL; and
| | - Wenjing Cao
- Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL; and
| | - Wen-Chao Song
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA
| | - X Long Zheng
- Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL; and
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Chegini A, Moghadami M, Maghary AH. Therapeutic Plasma Exchange in Tehran Between 2011 and 2014. Ther Apher Dial 2019; 24:230-234. [PMID: 31177634 DOI: 10.1111/1744-9987.12864] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 06/04/2019] [Accepted: 06/06/2019] [Indexed: 12/28/2022]
Abstract
The goal of therapeutic plasma exchange (TPE) is to remove autoantibodies, pathogenic molecules, immune complexes, toxins, high concentration lipoproteins, and pathological proteins. We aimed to present the most common indication of TPE and rate of admission to the intensive care unit. From 2011 to 2014, our retrospective study was conducted including 1069 inpatients from the Tehran Blood Transfusion Center, which was responsible for performing therapeutic apheresis in all 122 hospitals of Tehran. The patients, based on their TPE indication, were classified into five groups: hematological and oncological, neurological, renal, rheumatological diseases, and all the remaining diseases. We performed 6329 procedures of TPE on 1069 inpatients. Of the patients, 479 (44.8%) were male and 590 (55.2%) female. Their age varied from a minimum of 2 years to the maximum of 93 years. Overall, the mean of TPE sessions for each patient was 5.92 ± 3.9; 415 (38.8%) patients were admitted to the intensive care unit (ICU). ASFA categories I/II indications were considered an appropriate request for TPE, and 82.97% (887) of all TPE were suitable. The most frequent categories of TPE indications are as follows: neurological, hematological, and renal diseases. Class I/II indications in the neurological diseases, myasthenia gravis (21.7%), Guillain-Barré disease (21%), and multiple sclerosis (13.3%), were the most prevalent. In the hematological category, thrombotic thrombocytopenic purpura (TTP) (14.1%) was observed to be greater than the other indications. We observed that the most prevalent illnesses are neurological (myasthenia gravis), hematological (TTP), and renal.
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Affiliation(s)
- Azita Chegini
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Mehran Moghadami
- Apheresis Department, Tehran Blood Transfusion Center, Tehran, Iran
| | - Amir H Maghary
- Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
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Osman C, Jennings R, El-Ghariani K, Pinto A. Plasma exchange in neurological disease. Pract Neurol 2019; 20:92-99. [PMID: 31300488 DOI: 10.1136/practneurol-2019-002336] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2019] [Indexed: 01/08/2023]
Abstract
Plasma exchange is a highly efficient technique to remove circulating autoantibodies and other humoral factors rapidly from the vascular compartment. It was the first effective acute treatment for peripheral disorders such as Guillain-Barré syndrome and myasthenia gravis before intravenous immunoglobulin became available. The recent recognition of rapidly progressive severe antibody-mediated central nervous system disorders, such as neuromyelitis optica spectrum disorders and anti-N-methyl-D-aspartate-receptor encephalitis, has renewed interest in using plasma exchange for their acute treatment also. In this review we explain the principles and technical aspects of plasma exchange, review its current indications, and discuss the implications for its provision in the UK.
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Affiliation(s)
- Chinar Osman
- Neurosciences, Wessex Neurological Centre, Southampton, UK
| | | | - Khaled El-Ghariani
- Therapeutics and Tissue Services, NHS Blood and Transplant, Sheffield Teaching Hospitals NHS Trust and the University of Sheffield, Sheffield, UK
| | - Ashwin Pinto
- Neurosciences, Wessex Neurological Centre, Southampton, UK
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7
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De Palo T, Giordano M, Bellantuono R, Colella V, Troise D, Palumbo F, Caringella D. Therapeutic Apheresis in Children: Experience in a Pediatric Dialysis Center. Int J Artif Organs 2018. [DOI: 10.1177/039139880002301209] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The use of apheretic procedures in pediatric patients has always been restricted by technical difficulties and the low incidence of diseases requiring this kind of treatment. The aim of the present study was to describe the solutions adopted to solve technical difficulties related to priming, vascular access and monitoring and then to evaluate clinical results. Between 1982 and 2000, 51 consecutive children (28 male, 23 female) with a mean age of 4.9 ± 4.8 years (3 months – 14.8 years) and a mean weight of 19.7 ± 12.8 kg (5 – 52 kg), with renal and/or extra-renal diseases requiring apheretic procedures were selected for the study. The overall number of procedures performed were: 226 plasma-exchange (PE), 6 LDL-apheresis (LDL-A) and 8 protein A immunoadsorption (IAPA) sessions. Our therapeutic protocol involves hematic flux of 20 – 100 ml/min and ultrafiltration of 5–20 ml/min. In each 70–95 minute session we exchanged plasmatic volume with fresh frozen plasma or with a solution of 6% albumin in lactated Ringer's, using heparin (10–20 UI/kg/h). We used Paired Filtration Dialysis Monitor in PE and LDL-A; Citem 10 in IAPA. As plasma separator, we used a filter made of polypropylene, 0.2 m2 surface, 30 ml priming (Hemaplex BT 900). Hemolytic uremic syndrome was the most commonly treated disease (18/51 cases) with good results in 10/18 cases. We recorded, good results in vasculitis as well, in one girl with focal glomerulosclerosis in transplanted kidney and rapid improvement in all children with Guillaine-Barré Syndrome. PE treatment was effective in metabolic disorders such as tirosynemia and familiar hypercolesterolemia. Only 4/12 patients with acute liver failure due to viral hepatitis recovered. We had poor results in the remaining eight cases. Complications were rare and no viral infection was found in any patient. Our data show that it is possible to use these procedures in pediatric patients even though clinical indications and real effectiveness still need to be cleared up.
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Affiliation(s)
- T. De Palo
- Pediatric Nephrology and Dialysis, Children Hospital Giovanni XXIII, Bari - Italy
| | - M. Giordano
- Pediatric Nephrology and Dialysis, Children Hospital Giovanni XXIII, Bari - Italy
| | - R. Bellantuono
- Pediatric Nephrology and Dialysis, Children Hospital Giovanni XXIII, Bari - Italy
| | - V. Colella
- Pediatric Nephrology and Dialysis, Children Hospital Giovanni XXIII, Bari - Italy
| | - D. Troise
- Pediatric Cardiac Surgery, Children Hospital Giovanni XXIII, Bari - Italy
| | - F. Palumbo
- Institute of Urology, University of Bari, Bari - Italy
| | - D.A. Caringella
- Pediatric Nephrology and Dialysis, Children Hospital Giovanni XXIII, Bari - Italy
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8
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Accorsi P, Passeri C, Onofrillo D, Iacone A. Hyperviscosity Syndrome in Hematological Diseases and Therapeutic Apheresis. Int J Artif Organs 2018; 28:1032-8. [PMID: 16288442 DOI: 10.1177/039139880502801011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The hyperviscosity syndrome classified into pleiocytosic, sclerotic and sieric syndromes according to the blood components involved are characterized by a different degree of clinical signs and symptoms related to rheological modification of blood. Therapeutic management of these syndromes is complex and the choice of apheresis treatment is generally restricted to emergency episodes in order to overcome the acute phase and to reverse the symptoms until definitive therapy is effective.
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Affiliation(s)
- P Accorsi
- Department of Transfusion Medicine, Spirito Santo Civic Hospital, Pescara--Italy.
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Clark WF, Huang SHS, Walsh MW, Farah M, Hildebrand AM, Sontrop JM. Plasmapheresis for the treatment of kidney diseases. Kidney Int 2016; 90:974-984. [DOI: 10.1016/j.kint.2016.06.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 06/08/2016] [Accepted: 06/09/2016] [Indexed: 01/24/2023]
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Misanovic V, Pokrajac D, Zubcevic S, Hadzimuratovic A, Rahmanovic S, Dizdar S, Jonuzi A, Begic E. Plasmapheresis in Pediatric Intensive Care Unit. Med Arch 2016; 70:332-335. [PMID: 27994290 PMCID: PMC5136426 DOI: 10.5455/medarh.2016.70.332-335] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 09/25/2016] [Indexed: 11/17/2022] Open
Abstract
Introduction: Plasmapheresis also known as a therapeutic plasma exchange (TPE) is extracorporeal procedure by which individual components of plasma that are harmful or blood cells can be removed from organism by using a blood separation technology. Aim: To present the results of the implementation of plasmapheresis in children in the Department of Pediatric Intensive Care of Pediatric Clinic, Clinical center of Sarajevo University, Bosnia and Herzegovina. Patients and methods: Research (period from December 2011 to June 2016) analyzed 66 plasmapheresis (11 patients–6 plasmapheresis per patient). Results: Out of 11 patients, 7 (63.6%) were girls and 4 (36.4%) were boys. The average age of patients was 11.6 ± 3.9 years (the youngest patient had 4 years and 7 months, while the oldest had 16 years and 10 months). Plasmapheresis were significantly more often done in the winter and summer. Underlying disease was in 54.5% of cases of neurological origin. The treatment was in form of receiving IVIG in 7 patients, or the application of mechanical ventilation in 6 patients. The most common complication was hypotension, which occurred in 45.5% of patients, followed by bleeding in 36.3%, hypercoagulability in 27.2% of patients and hematoma in 27.2% of patients. Lethal outcome occurred in 3 (27.2%) patients. Conclusion: Plasmapheresis represents an invasive method due to need for placement of centralized venous catheter that provides adequate blood flow during the procedure. Although complications can be serious, they are rare and are mainly related to the presence of central venous catheter, hemostasis disorders due to use of anticoagulant therapy, and hypotension of the cardiovascular system. It should be noted that for success of plasmapheresis in children multidisciplinary approach is necessary (children’s nephrologist, neuropediatrician, intensive care doctor) as well as well-trained team of doctors and nurses with the acquired knowledge and skills.
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Affiliation(s)
- Verica Misanovic
- Pediatric Clinic, University Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Danka Pokrajac
- Pediatric Clinic, University Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Smail Zubcevic
- Pediatric Clinic, University Clinical Center Sarajevo, Bosnia and Herzegovina
| | | | - Samra Rahmanovic
- Pediatric Clinic, University Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Selma Dizdar
- Pediatric Clinic, University Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Asmir Jonuzi
- Clinic for Pediatric Surgery, University Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Edin Begic
- Health Center Maglaj, Maglaj, Bosnia and Herzegovina
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Linenberger ML, Price TH. Use of Cellular and Plasma Apheresis in the Critically Ill Patient: Part II: Clinical Indications and Applications. J Intensive Care Med 2016; 20:88-103. [PMID: 15855221 DOI: 10.1177/0885066604273479] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Apheresis is the process of separating the blood and removing or manipulating a cellular or plasma component for therapeutic benefit. Such procedures may be indicated in the critical care setting as primary or adjunctive therapy for certain hematologic, neurologic, renal, and autoimmune/rheumatologic disorders. In part I of this series, the technical aspects of apheresis were described and the physiologic rationale and clinical considerations were discussed. This review highlights the pathophysiologic basis, specific clinical indications, and treatment parameters for disorders that more commonly require management in the intensive care unit. The choice of plasma or cellular apheresis in these cases is guided by wellaccepted, evidence-based clinical treatment guidelines. For some disorders, such as liver failure, severe sepsis, and multiple-organ dysfunction syndrome, apheresis treatment approaches remain experimental. Ongoing studies are investigating the potential utility of conventional plasma exchange, ex vivo plasma manipulation, and newer technologies for these and other disorders in severely ill patients.
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Affiliation(s)
- Michael L Linenberger
- Apheresis and Cellular Therapy, Seattle Cancer Care Alliance, Seattle, WA 98109, USA.
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12
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Thejeel B, Garg AX, Clark WF, Liu AR, Iansavichus AV, Hildebrand AM. Long-term outcomes of thrombotic microangiopathy treated with plasma exchange: A systematic review. Am J Hematol 2016; 91:623-30. [PMID: 26910131 DOI: 10.1002/ajh.24339] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/17/2016] [Indexed: 12/12/2022]
Abstract
With the adoption of plasma exchange as standard treatment for thrombotic microangiopathy (TMA), more patients are surviving and long-term outcomes have greater relevance. We conducted a systematic review to synthesize and evaluate the quality of evidence on long-term outcomes of TMA among adults treated with plasma exchange and to identify factors that may be associated with a worse long-term prognosis. We searched databases from 1980 to 2013 for eligible articles published in any language. We included studies that reported outcomes in at least ten adults with a history of TMA treated with plasma exchange and at least 6 months of follow-up. We abstracted data in duplicate and assessed the methodological quality of each study using an assessment tool developed based on recommended validity criteria. We screened 6672 articles, reviewed 213, and included 34 studies totaling 1182 patients (study median [range], 24 [10-118]). The mean (or median) follow-up ranged from 6 months to 13 years. The cumulative incidence of relapse and mortality was highly variable and ranged from 3 to 84 and 0 to 61%, respectively. The incidence of other outcomes across 10 studies also varied (outcomes included hypertension, kidney disease, preeclampsia, stroke, seizure, severe cognitive impairment, and depression); in three other studies, long-term neurocognitive function and health-related quality of life were significantly lower than in the general population. Patients who survive an episode of TMA may be susceptible to long-term vascular complications, but the magnitude of this risk and how to mitigate it remains unclear. Am. J. Hematol. 91:623-630, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Bashiar Thejeel
- Schulich School of Medicine; Western University; London Ontario Canada
- Kidney Clinical Research Unit, London Health Sciences Centre; London Ontario Canada
| | - Amit X. Garg
- Kidney Clinical Research Unit, London Health Sciences Centre; London Ontario Canada
- Department of Epidemiology and Biostatistics; Western University; London Ontario Canada
- Division of Nephrology; Western University; London Ontario Canada
| | - William F. Clark
- Kidney Clinical Research Unit, London Health Sciences Centre; London Ontario Canada
- Division of Nephrology; Western University; London Ontario Canada
| | - Aiden R. Liu
- Kidney Clinical Research Unit, London Health Sciences Centre; London Ontario Canada
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Abstract
The biology of atypical hemolytic uremic syndrome has been shown to involve inability to limit activation of the alternative complement pathway, with subsequent damage to systemic endothelial beds and the vasculature, resulting in the prototypic findings of a thrombotic microangiopathy. Central to this process is the formation of the terminal membrane attack complex C5b-9. Recently, application of a monoclonal antibody that specifically binds to C5, eculizumab, became available to treat patients with atypical hemolytic uremic syndrome, replacing plasma exchange or infusion as primary therapy. This review focuses on the evidence, based on published clinical trials, case series, and case reports, on the efficacy and safety of this approach.
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Affiliation(s)
- Lilian M Pereira Palma
- Pediatric Nephrology, State University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Craig B Langman
- The Feinberg School of Medicine, Northwestern University, and the Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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14
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Gashti CN. Membrane-based Therapeutic Plasma Exchange: A New Frontier for Nephrologists. Semin Dial 2016; 29:382-90. [PMID: 27062015 DOI: 10.1111/sdi.12506] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Therapeutic plasma exchange has long been utilized to manage a variety of immune-mediated diseases. The underlying principle is the removal of a circulating pathogenic substance from the plasma and substitution with a replacement fluid. Different methodologies of plasma separation include the use of centrifuge, which relies on the variation in the specific gravity of blood components, and membrane-based separation, which relies on particle size. With advancements in technology and clinical insight into disease pathophysiology, membrane technology has become more biocompatible, safer, and more adaptable to conventional hemodialysis and hemofiltration machines. As such, nephrologists, who are familiar with management of extracorporeal blood purification systems, are increasingly involved with membrane-based plasma separation. This review aims to highlight the technical aspects of membrane-based separation, review the prescription for therapy, and draw comparisons with the centrifuge-based technique when applicable.
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Affiliation(s)
- Casey N Gashti
- Section of Nephrology, Department of Medicine, Rush University Medical Center, Chicago, Illinois.
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15
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Mann SA, McCleskey B, Marques MB, Adamski J. Establishing an institutional therapeutic apheresis registry. J Clin Apher 2016; 31:516-522. [DOI: 10.1002/jca.21443] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 12/02/2015] [Indexed: 11/12/2022]
Affiliation(s)
- Steven A. Mann
- Department of Pathology and Laboratory Medicine, Indiana University; Indianapolis Indiana
| | - Brandi McCleskey
- Department of Pathology; University of Alabama at Birmingham (UAB); Birmingham Alabama
| | - Marisa B. Marques
- Department of Pathology; University of Alabama at Birmingham (UAB); Birmingham Alabama
| | - Jill Adamski
- Department of Laboratory Medicine and Pathology; Mayo Clinic Arizona; Phoenix Arizona
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16
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Soucemarianadin M, Benhamou Y, Delmas Y, Pichereau C, Maury E, Pène F, Halimi JM, Presne C, Thouret JM, Veyradier A, Coppo P. Twice-daily therapeutical plasma exchange-based salvage therapy in severe autoimmune thrombotic thrombocytopenic purpura: the French TMA Reference Center experience. Eur J Haematol 2016; 97:183-91. [DOI: 10.1111/ejh.12706] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Myriam Soucemarianadin
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de Réanimation; Centre Hospitalier Métropole Savoie; Chambéry France
| | - Ygal Benhamou
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Inserm U1096; Rouen France
- Service de Médecine Interne; CHU Charles Nicolle; Rouen France
| | - Yahsou Delmas
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de Néphrologie Transplantation Dialyse; Centre Hospitalier Universitaire; Bordeaux France
| | - Claire Pichereau
- Sorbonne Université; UPMC Univ Paris 06; Paris France
- Service de Réanimation Médicale; CHU Saint-Antoine; Paris France
| | - Eric Maury
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Sorbonne Université; UPMC Univ Paris 06; Paris France
- Service de Réanimation Médicale; CHU Saint-Antoine; Paris France
| | - Frédéric Pène
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de Réanimation Polyvalente; Hôpital Cochin; Paris France
- Université Paris 5; Paris France
| | - Jean-Michel Halimi
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de néphrologie-immunologie clinique; hôpital Bretonneau; Tours France
- EA 4245; université François-Rabelais 2; boulevard Tonnellé; Tours France
| | - Claire Presne
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service de Néphrologie - Médecine Interne; Hôpital Sud; Amiens France
| | - Jean-Marc Thouret
- Service de Réanimation; Centre Hospitalier Métropole Savoie; Chambéry France
| | - Agnès Veyradier
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Service d'Hématologie Biologique; Hôpital Lariboisière; Paris France
- Univ. Paris Diderot; Sorbonne Paris Cité; Paris France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques; Hôpital Saint-Antoine; Paris France
- Sorbonne Université; UPMC Univ Paris 06; Paris France
- Inserm U1009; Institut Gustave Roussy; Villejuif France
- Service d'Hématologie; Hôpital Saint-Antoine; Paris France
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17
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Clark WF, Rock G, Barth D, Arnold DM, Webert KE, Yenson PR, Kelton JG, Li L, Foley SR. A phase-II sequential case-series study of all patients presenting to four plasma exchange centres with presumed relapsed/refractory thrombotic thrombocytopenic purpura treated with rituximab. Br J Haematol 2015; 170:208-17. [PMID: 25855259 DOI: 10.1111/bjh.13408] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/16/2015] [Indexed: 11/26/2022]
Abstract
The primary objective of this phase II study was to evaluate the efficacy of rituximab in the management of adult patients with physician-diagnosed presumed thrombotic thrombocytopenic purpura (TTP); relapsed or refractory. We conducted a multicentre study in four Canadian hospital-based apheresis units. Forty patients with presumed TTP (20 refractory and 20 relapsing) were sequentially enrolled and all received rituximab in a standardized manner. A complete response was documented in 14 of 19 refractory patients by week 8 and 15/16 were alive and in remission at 52 weeks (one patient was lost to follow-up, one was a non-responder, and three died). Among relapsing patients, 16/18 had a complete response at week 8 and 18/18 at week 52 (one patient lost to follow-up and one withdrew). At 1 year, all relapsing and 85% of refractory patients survived. Of 38/40 patients who had ADMATS13 testing at study entry, 13/19 refractory and 10/19 relapsing patients had ADAMTS13 < 10% (typical TTP); whereas 6/19 refractory and 9/19 relapsing cases had ADAMTS13 > 10% (other thrombotic microangiopathy; TMA). Refractory-typical TTP in contrast to refractory-other TMA and all relapsing patients treated with plasma exchange and rituximab, were less likely to be responsive and more likely to die or relapse.
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Affiliation(s)
- William F Clark
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Gail Rock
- Department of Pathology, University of Ottawa, Ottawa, ON, Canada
| | - David Barth
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Donald M Arnold
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kathyrn E Webert
- Division of Hematology and Thromboembolism, Department of Medicine and Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Paul R Yenson
- Division of Hematology, Department of Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | - John G Kelton
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Lihua Li
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Steven R Foley
- Division of Clinical Pathology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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Gafoor VA, Jose J, Saifudheen K, Musthafa M. Plasmapheresis in neurological disorders: Experience from a tertiary care hospital in South India. Ann Indian Acad Neurol 2015; 18:15-9. [PMID: 25745304 PMCID: PMC4350207 DOI: 10.4103/0972-2327.144301] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 07/17/2014] [Accepted: 07/18/2014] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Therapeutic plasma exchange (PE) or plasmapheresis is the treatment of choice in many neurological disorders. Even though it is safe in experienced hands, there is a major concern about its safety among physicians. OBJECTIVES To analyze our experience with 230 patients who underwent PE for various neurological disorders. MATERIALS AND METHODS Retrospective review of PE procedures done during a period of 48 months, from July 2007 to June 2011 in a tertiary care teaching hospital in South India. Indications, clinical results and technical factors are discussed. RESULTS The main indication for PE was GBS (203 patients; 88.3%). Age of patients ranged from 14-65 (mean = 42.3 years). The most common complications were paraesthesias and/or cramps (36.1%) and hypotension (32.2%). Four pregnant patients who underwent PE had good recovery with one intrauterine death. There was no mortality. CONCLUSION The analysis of 240 cases of PE done in our department shows that the procedure is safe, with only minimal procedure related complications and no mortality.
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Affiliation(s)
- V Abdul Gafoor
- Department of Neurology, Medical College, Calicut, Kerala, India
| | - James Jose
- Department of Neurology, Medical College, Calicut, Kerala, India
| | - K Saifudheen
- Department of Neurology, Medical College, Calicut, Kerala, India
| | - Mohamed Musthafa
- Department of Neurology, Medical College, Calicut, Kerala, India
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19
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Hong H, Xiao W, Stempak LM, Sandhaus LM, Maitta RW. Absolute immature platelet count dynamics in diagnosing and monitoring the clinical course of thrombotic thrombocytopenic purpura. Transfusion 2014; 55:756-65. [PMID: 25370931 DOI: 10.1111/trf.12912] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 08/21/2014] [Accepted: 09/08/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a life-threatening diagnosis requiring prompt initiation of therapeutic plasma exchange (TPE). Measurement of immature platelet (PLT) fraction (%-IPF) differentiates PLT consumption or destruction from hypoproduction. STUDY DESIGN AND METHOD Our study evaluated %-IPF changes over the course of TTP treated with TPE and as a measure of treatment efficacy. Eleven idiopathic TTP patients, two human immunodeficiency virus (HIV)-associated TTP patients, and five non-TTP patients with thrombocytopenia were enrolled into our study. All patients were treated with TPE and had ADAMTS13 activity measured. RESULTS All idiopathic TTP patients had a significantly increased %-IPF and decreased absolute immature PLT count (A-IPC) and PLT count at presentation. An A-IPC value of less than 5 × 10(9) /L at presentation has 84.6% sensitivity, 80% specificity, and 91.7% positive predictive value for diagnosing TTP. A concurrent steady decline in %-IPF and increased PLT counts toward normal was observed in TTP patients undergoing TPE. The A-IPC, however, showed an increase and decrease curve that was not seen in the two HIV-associated TTP patients with no response to TPE and the five non-TTP patients. More importantly, reaching an A-IPC ratio of 3 compared to baseline value during TPE can readily differentiate idiopathic TTP from the other two groups and is correlated with good clinical responses to TPE. An abrupt increase of A-IPC during TPE was also noted in a TTP patient who relapsed 3 days before PLT count decrease. A-IPC is positively correlated with ADAMTS13 activity at presentation but negatively correlated with ADAMTS13 activity during recovery. CONCLUSION A-IPC should be routinely analyzed for diagnosing and monitoring TTP patients.
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Affiliation(s)
- Hong Hong
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Wenbin Xiao
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Lisa M Stempak
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Linda M Sandhaus
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Robert W Maitta
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, Ohio.,Case Western Reserve University School of Medicine, Cleveland, Ohio
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20
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Barrows BD, Teruya J. Use of the ADAMTS13 activity assay improved the accuracy and efficiency of the diagnosis and treatment of suspected acquired thrombotic thrombocytopenic purpura. Arch Pathol Lab Med 2014; 138:546-9. [PMID: 24678685 DOI: 10.5858/arpa.2013-0170-oa] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Acquired thrombotic thrombocytopenic purpura (A-TTP) is a rare but significant disease requiring rapid diagnosis and treatment. The diagnosis is often difficult because of variability in the presence of specific clinical criteria. The primary etiology of A-TTP involves inhibitors directed against ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13). Literature has shown that the ADAMTS13 activity assay is sensitive and specific for identifying cases of A-TTP, and application of this test as an on-site screening method has not been fully explored. OBJECTIVE Our objective is to determine if the ADAMTS13 activity assay can be used as a successful, on-site diagnostic modality to rapidly identify cases of A-TTP and prevent unnecessary use of prophylactic therapeutic plasma exchange. DESIGN A retrospective analysis was performed including 152 patients with clinically suspected A-TTP, screened using the ADAMTS13 activity assay. Results were correlated with potential therapeutic plasma exchange treatment for all cases highly suspicious for A-TTP and evaluated for unnecessary patient morbidity and financial cost. RESULTS The ADAMTS13 activity assay had an overall sensitivity and specificity of 100% and 99%, respectively. The positive predictive value was 91% and the negative predictive value was 100%. In 95% of the studies ordered, A-TTP was ruled out, leading to decreased patient morbidity and $1.7 million of potential treatment costs avoided. CONCLUSION Implementation of the fluorescence energy transfer-based ADAMTS13 activity assay as a point-of-care laboratory study decreased patient morbidity while also directing more efficient employment of therapeutic plasma exchange in cases of suspected A-TTP.
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Affiliation(s)
- Brad D Barrows
- From the Departments of Pathology & Immunology (Dr Barrows) and Pediatrics and Medicine (Dr Teruya), Baylor College of Medicine, Houston, Texas
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21
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Morales Borges RH, Nieves GC, Martínez MR, Ramos RV, Pedraza Otero LI, Vargas CN, Pedraza GO, Jiménez JJM. Therapeutic aphaeresis: Experience in Puerto Rico. Transfus Apher Sci 2014; 50:473-8. [DOI: 10.1016/j.transci.2014.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 01/22/2014] [Accepted: 02/24/2014] [Indexed: 11/25/2022]
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Hildebrand AM, Huang SHS, Clark WF. Plasma exchange for kidney disease: what is the best evidence? Adv Chronic Kidney Dis 2014; 21:217-27. [PMID: 24602471 DOI: 10.1053/j.ackd.2014.01.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 01/14/2014] [Accepted: 01/15/2014] [Indexed: 11/11/2022]
Abstract
Therapeutic plasma exchange (TPE) has been used as adjunctive therapy for various kidney diseases dating back to the 1970s. In many cases, support for TPE was on mechanistic grounds given the potential to remove unwanted large molecular-weight substances such as autoantibodies, immune complexes, myeloma light chains, and cryoglobulins. More recently, growing evidence from randomized controlled trials, meta-analyses, and prospective studies has provided insights into more rational use of this therapy. This report describes the role of TPE for the 6 most common kidney indications in the 2013 Canadian Apheresis Group (CAG) registry and the evidence that underpins current recommendations and practice. These kidney indications include thrombotic microangiopathy, antiglomerular basement membrane disease, anti-neutrophil cytoplasmic antibody-associated vasculitis, cryoglobulinemia, recurrence of focal and segmental glomerulosclerosis in the kidney allograft, and kidney transplantation.
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23
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Morgan SM, Zantek ND, Carpenter AF. Therapeutic plasma exchange in neuromyelitis optica: A case series. J Clin Apher 2013; 29:171-7. [DOI: 10.1002/jca.21304] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 08/11/2013] [Accepted: 09/20/2013] [Indexed: 12/18/2022]
Affiliation(s)
- Shanna M. Morgan
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Nicole D. Zantek
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Adam F. Carpenter
- Department of Neurology; University of Minnesota; Minneapolis Minnesota
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Abstract
It is widely accepted that the main common pathogenetic pathway in multiple sclerosis (MS) involves an immune-mediated cascade initiated in the peripheral immune system and targeting CNS myelin. Logically, therefore, the therapeutic approaches to the disease include modalities aiming at downregulation of the various immune elements that are involved in this immunologic cascade. Since the introduction of interferons in 1993, which were the first registered treatments for MS, huge steps have been made in the field of MS immunotherapy. More efficious and specific immunoactive drugs have been introduced and it appears that the increased specificity for MS of these new treatments is paralleled by greater efficacy. Unfortunately, this seemingly increased efficacy has been accompanied by more safety issues. The immunotherapeutic modalities can be divided into two main groups: those affecting the acute stages (relapses) of the disease and the long-term treatments that are aimed at preventing the appearance of relapses and the progression in disability. Immunomodulating treatments may also be classified according to the level of the 'immune axis' where they exert their main effect. Since, in MS, a neurodegenerative process runs in parallel and as a consequence of inflammation, early immune intervention is warranted to prevent progression of relapses of MS and the accumulation of disability. The use of neuroimaging (MRI) techniques that allow the detection of silent inflammatory activity of MS and neurodegeneration has provided an important tool for the substantiation of the clinical efficacy of treatments and the early diagnosis of MS. This review summarizes in detail the existing information on all the available immunotherapies for MS, old and new, classifies them according to their immunologic mechanisms of action and proposes a structured algorithm/therapeutic scheme for the management of the disease.
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25
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26
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Autoimmune diseases in the intensive care unit. An update. Autoimmun Rev 2013; 12:380-95. [DOI: 10.1016/j.autrev.2012.06.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 06/12/2012] [Indexed: 12/18/2022]
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27
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Clark W. Plasma exchange for renal disease: Evidence and use 2011. J Clin Apher 2012; 27:112-6. [DOI: 10.1002/jca.21221] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Accepted: 02/21/2012] [Indexed: 11/06/2022]
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Sato D, Callegaro D, Lana-Peixoto MA, Fujihara K. Treatment of neuromyelitis optica: an evidence based review. ARQUIVOS DE NEURO-PSIQUIATRIA 2012; 70:59-66. [DOI: 10.1590/s0004-282x2012000100012] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 09/05/2011] [Indexed: 12/18/2022]
Abstract
Neuromyelitis optica (NMO) is an inflammatory disease of the central nervous system characterized by severe optic neuritis and transverse myelitis, usually with a relapsing course. Aquaporin-4 antibody is positive in a high percentage of NMO patients and it is directed against this water channel richly expressed on foot processes of astrocytes. Due to the severity of NMO attacks and the high risk for disability, treatment should be instituted as soon as the diagnosis is confirmed. There is increasing evidence that NMO patients respond differently from patients with multiple sclerosis (MS), and, therefore, treatments for MS may not be suitable for NMO. Acute NMO attacks usually are treated with high dose intravenous corticosteroid pulse and plasmapheresis. Maintenance therapy is also required to avoid further attacks and it is based on low-dose oral corticosteroids and non-specific immunosuppressant drugs, like azathioprine and mycophenolate mofetil. New therapy strategies using monoclonal antibodies like rituximab have been tested in NMO, with positive results in open label studies. However, there is no controlled randomized trial to confirm the safety and efficacy for the drugs currently used in NMO.
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Brunetta Gavranić B, Bašić-Jukić N, Kes P. Changes in Indications for Therapeutic Plasma Exchange Over the Last 27 Years in Croatia. Ther Apher Dial 2011; 15:587-92. [DOI: 10.1111/j.1744-9987.2011.00986.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sussmane JB, Torbati D, Gitlow HS. Measuring the quality of therapeutic apheresis care in the pediatric intensive care unit. J Clin Apher 2011; 27:43-50. [PMID: 22095668 DOI: 10.1002/jca.20318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 10/11/2011] [Indexed: 11/12/2022]
Abstract
Our goal was to measure the quality of care provided in the Pediatric Intensive Care Unit (PICU) during Therapeutic Apheresis (TA). We described the care as a step by step process. We designed a flow chart to carefully document each step of the process. We then defined each step with a unique clinical indictor (CI) that represented the exact task we felt provided quality care. These CIs were studied and modified for 1 year. We measured our performance in this process by the number of times we accomplished the CI vs. the total number of CIs that were to be performed. The degree of compliance, with these clinical indicators, was analyzed and used as a metric for quality by calculating how close the process is running exactly as planned or "in control." The Apheresis Process was in control (compliance) for 47% of the indicators, as measured in the aggregate for the first observational year. We then applied the theory of Total Quality Management (TQM) through our Design, Measure, Analyze, Improve, and Control (DMAIC) model. We were able to improve the process and bring it into control by increasing the compliance to > 99.74%, in the aggregate, for the third and fourth quarter of the second year. We have implemented TQM to increase compliance, thus control, of a highly complex and multidisciplinary Pediatric Intensive Care therapy. We have shown a reproducible and scalable measure of quality for a complex clinical process in the PICU, without additional capital expenditure.
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Affiliation(s)
- Jeffrey B Sussmane
- Division of Critical Care Medicine, Miami Children's Hospital, Miami, Florida.
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31
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Lin YN, Chou JW, Cheng KS, Peng CY, Jeng LB, Chiang IP. Treatment of Fulminant Autoimmune Hepatitis: Corticosteroid Therapy or Liver Transplantation? A Case Report and Literature Review. Gastroenterology Res 2011; 4:231-235. [PMID: 27957021 PMCID: PMC5139849 DOI: 10.4021/gr323w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2011] [Indexed: 11/22/2022] Open
Abstract
Autoimmune hepatitis initially presenting as fulminant hepatic failure is rare in clinical practice. Although corticosteroid is considered as a good therapeutic agent in treating autoimmune hepatitis in the literature, the effect of corticosteroid in treating fulminant autoimmune hepatitis is still controversial. Because corticosteroid therapy for fulminant autoimmune hepatitis can sometimes overlook any future treatment such as delay the timing of liver transplantation and precipitate postoperative complications. We report a case of a 41-year-old female who was admitted to our hosptal because of acute hepatitis with severe jaundice. Type 1 autoimmune hepatitis complicated by fulminant hepatic failure was diagnosed on the basis of her clinical course and laboratory findings. Although we prescribed aggressive medical treatment, plasma transfusion, and plasma exchange therapy, her liver function deteriorated progressively and she developed hepatic coma later. Finally, her fulminant hepatic fuilure gained dramatic improvement after receiving an orthotopic liver transplant from her younger brother. High MELD score and poor treatment response of corticosteroid therapy are indicators of poor prognosis and need of prompt OLT. Moreover, the preoperative interventions should be applied carefully ensuring that they do not delay OLT or precipitate postoperative complications such as infection, bleeding, or poor wound healing.
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Affiliation(s)
- Yen-Nien Lin
- Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Jen-Wei Chou
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan; These authors contribute equally to this article
| | - Ken-Sheng Cheng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan; These authors contribute equally to this article
| | - Cheng-Yuan Peng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Long-Bin Jeng
- Organ transplantation center, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - I-Ping Chiang
- Department of Pathology, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
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Therapeutic plasma exchange for the management of refractory systemic autoimmune diseases: Report of 31 cases and review of the literature. Autoimmun Rev 2011; 10:679-84. [DOI: 10.1016/j.autrev.2011.04.028] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Plasmaféresis como tratamiento de la hipertrigliceridemia grave. ACTA ACUST UNITED AC 2011; 58:319-20. [DOI: 10.1016/j.endonu.2010.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 12/11/2010] [Accepted: 12/14/2010] [Indexed: 11/19/2022]
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34
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Early diagnosis and management of postpartum hemolytic uremic syndrome with plasma exchange. Transfus Apher Sci 2011; 44:257-62. [DOI: 10.1016/j.transci.2011.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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35
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Shahidi S, Memarzadeh M, Kamali M, Naini AE. Trend of indications for therapeutic plasma exchange at an Iranian university hospital. Transfus Apher Sci 2011; 44:119-22. [DOI: 10.1016/j.transci.2011.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 01/20/2011] [Indexed: 12/19/2022]
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Rituximab for managing relapsing or refractory patients with idiopathic thrombotic thrombocytopenic purpura--haemolytic uraemic syndrome. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2010; 8:203-10. [PMID: 20671883 DOI: 10.2450/2009.0101-09] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 08/06/2009] [Indexed: 11/21/2022]
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Balogun RA, Ogunniyi A, Sanford K, Okafor C, Lobo PI, Siami G, Barcia J, Kaplan AA. Therapeutic apheresis in special populations. J Clin Apher 2010; 25:265-74. [DOI: 10.1002/jca.20250] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Caramazza D, Quintini G, Abbene I, Malato A, Saccullo G, Coco LL, Di Trapani R, Palazzolo R, Barone R, Mazzola G, Rizzo S, Ragonese P, Aridon P, Abbadessa V, Siragusa S. Relapsing or refractory idiopathic thrombotic thrombocytopenic purpura-hemolytic uremic syndrome: the role of rituximab. Transfusion 2010; 50:2753-60. [DOI: 10.1111/j.1537-2995.2010.02763.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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39
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40
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Utilidad de la plasmaféresis en cuidados intensivos. Med Intensiva 2010; 34:74-8. [DOI: 10.1016/j.medin.2009.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2009] [Revised: 03/20/2009] [Accepted: 03/30/2009] [Indexed: 11/21/2022]
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Brémaud M, Giraud C, Boinot C, Caranobe C, Macchi L, Gohler C, Guilhot F. [Three cases of IgM monoclonal gammopathy with haemostasis dysfunction]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2009; 28:892-896. [PMID: 19767170 DOI: 10.1016/j.annfar.2009.07.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Accepted: 07/30/2009] [Indexed: 05/28/2023]
Abstract
We relate three cases of IgM gammopathy with haemostatic dysfunction in the perioperative period. The acquired von Willebrand syndrome due to IgM gammopathy is rare and sometimes serious. Its different treatments and their efficiency are discussed: desmopressin, intravenous gammaglobulin, chemotherapy and plasmapheresis.
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Affiliation(s)
- M Brémaud
- Service d'anesthésie-réanimation, clinique des Cèdres, Cornebarrieu, France.
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Bouw MC, Dors N, van Ommen H, Ramakers-van Woerden NL. Thrombotic thrombocytopenic purpura in childhood. Pediatr Blood Cancer 2009; 53:537-42. [PMID: 19544391 DOI: 10.1002/pbc.22094] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare disease, especially in childhood, and has a high mortality rate in the absence of appropriate treatment. It is characterised by microangiopathic haemolytic anaemia and consumptive thrombocytopenia. TTP may be difficult to distinguish from haemolytic uraemic syndrome (HUS) because of similar clinical manifestations and laboratory findings. In the past, TTP and HUS have often been considered to represent variable expressions of a single entity. Our increased understanding of the pathogenesis of TTP has in turn resulted in significant improvements in its treatment and outcomes. Several immunomodulating agents are currently being used with variable outcomes.
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Affiliation(s)
- Maria C Bouw
- Department of Paediatrics, Meander Medical Centre, Amersfoort, The Netherlands
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Kuang W, Tan J, Yuan X, Duan J, Jin F, Jin Z, Wang W, Li X, Wang Q, Duan Y, Liu Y. Plasma exchange therapy holds promise in the management of advanced cancer. Med Hypotheses 2009; 72:533-4. [PMID: 19168291 DOI: 10.1016/j.mehy.2008.11.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 11/05/2008] [Accepted: 11/10/2008] [Indexed: 11/30/2022]
Abstract
Cancer is now emerging as the second most common cause of death worldwide. Currently the most widely used treatments for solid cancer are surgery, chemotherapy, radiotherapy and hormone therapy, all of which are of limited effects in improvement of the survival. It is well-established that circulating factors are involved in the development of cancer. And plasma exchange is a well-established therapeutic procedure commonly used in many autoimmune diseases through the elimination of pathologic mediators, including auto-antibodies, complement components, and cytokines. Thus, we hypothesize that plasma exchange therapy alone or in combination with the routine therapeutics should be considered as an alternative for the present treatments. Future clinical studies are needed to validate the hypothesis.
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Affiliation(s)
- Wei Kuang
- Department of Stomatology, Guangzhou General Hospital of Guangzhou Military Command, 111 Liuhua Road, Guangzhou, Guangdong 510010, People's Republic of China
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Levandovsky M, Harvey D, Lara P, Wun T. Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS): a 24-year clinical experience with 178 patients. J Hematol Oncol 2008; 1:23. [PMID: 19046460 PMCID: PMC2613392 DOI: 10.1186/1756-8722-1-23] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Accepted: 12/01/2008] [Indexed: 11/10/2022] Open
Abstract
Background Thrombotic thrombocytopenic purpura and the hemolytic uremic syndrome (TTP-HUS) are related and uncommon disorders with a high fatality and complication rate if untreated. Plasma exchange therapy has been shown to produce high response rates and improve survival in patients with many forms of TTP-HUS. We performed a retrospective cohort study of 178 consecutively treated patients with TTP-HUS and analyzed whether clinical or laboratory characteristics could predict for important short- and long-term outcome measures. Results Overall 30-day mortality was 16% (n = 27). 171 patients (96%) received plasma exchange as the principal treatment, with a mean of 8 exchanges and a mean cumulative infused volume of 42 ± 71 L of fresh frozen plasma. The rate of complete response was 65% or 55% depending on whether this was defined by a platelet count of 100,000/μl or 150,000/μl, respectively. The rate of relapse was 18%. The Clinical Severity Score did not predict for 30-day mortality or relapse. The time to complete response did not predict for relapse. Renal insufficiency at presentation was associated with a decreased risk of relapse, with each unit increase in serum creatinine associated with a 40% decreased odds of relapse. 72% of our cohort had an idiopathic TTP-sporadic HUS, while 17% had an underlying cancer, received a solid organ transplant or were treated with a mitomycin-based therapy. The estimated overall 5-year survival was 55% and was significantly better in those without serious underlying conditions. Conclusion Plasma exchange therapy produced both high response and survival rates in this large cohort of patients with TTP-HUS. The Clinical Severity Score did not predict for 30-day mortality or relapse, contrary to our previous findings. Interestingly, the presence of renal insufficiency was associated with a decreased risk of relapse. The most important predictor of mortality was the presence or absence of a serious underlying disorder.
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Affiliation(s)
- Mark Levandovsky
- Division of Hematology and Oncology, UC Davis School of Medicine, Sacramento, CA, USA.
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Chou JW, Yu CJ, Chuang PH, Lai HC, Hsu CH, Cheng KS, Peng CY, Chiang IP. Successful Treatment of Fosinopril-Induced Severe Cholestatic Jaundice with Plasma Exchange. Ann Pharmacother 2008; 42:1887-92. [PMID: 19017832 DOI: 10.1345/aph.1l229] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To describe a case of fosinopril-induced severe cholestatic jaundice successfully treated with plasma exchange. Case Summary: A 78-year-old Taiwanese male presented with yellowish skin and generalized itching one month after starting fosinopril 10 mg once a day. Other drugs taken by the patient were excluded as the probable cause of jaundice. Diagnostic modalities, including abdominal ultrasound, computed tomography, and endoscopic retrograde cholangiopancreatography, revealed no evidence of biliary tract obstruction or intraabdominal tumor. According to the Council for International Organizations of Medical Science (CIOMS) scale, fosinopril was a highly probable cause of the patient's jaundice. Liver biopsy showed cholestasis without bile duct damage. Based on results of the CIOMS scale assessment and pathological characteristics of the liver, the diagnosis was highly probable that fosinopril had induced cholestatic jaundice in our patient. During hospitalization, the patient developed severe jaundice and liver failure, despite conservative treatment and withdrawal of fosinopril. He underwent a 5-day course of plasma exchange therapy, and the serum bilirubin level declined rapidly after treatment. His liver function returned to normal 2 months after treatment. Discussion: Angiotensin-converting enzyme (ACE) inhibitor–induced hepatotoxicity is rare and only a few cases, with most involving captopril, have been reported in the English-language literature. Hepatotoxicity caused by fosinopril is extremely rare. Most ACE inhibitor–induced hepatotoxicity is mild and transient, but it can be fatal. Although orthotopic liver transplantation (OLT) is the standard method for treating drug-induced liver failure, plasma exchange therapy is an alternative therapeutic method or a bridge to OLT for treating liver failure. Conclusions: Plasma exchange therapy may play a valuable role in the treatment of fosinopril-induced cholestatic jaundice and liver failure. This intervention can be considered for temporary liver support until recovery or OLT.
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Affiliation(s)
- Jen-Wei Chou
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Ju Yu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital
| | - Po-Heng Chuang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital
| | - Hsueh-Chou Lai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital
| | | | - Ken-Sheng Cheng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital
| | - Cheng-Yuan Peng
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital
| | - I-Ping Chiang
- Department of Pathology, China Medical University Hospital
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Vijay A, Gertz MA. Current Treatment Options for Waldenström Macroglobulinemia. ACTA ACUST UNITED AC 2008; 8:219-29. [DOI: 10.3816/clm.2008.n.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
BACKGROUND Therapeutic plasma exchange (TPE) is an extracorporeal blood purification method for the treatment of diseases in which pathological proteins have to be eliminated. In the aim to demonstrate our single center activity, we analyzed our data since 2 years. METHODS Between years 2002 and 2005, 104 TPE procedures were performed on 42 patients. Median age and male/female ratio were 32 (range, 17-56) and 24/18, respectively. Departments those referred the majority of the TPE were neurology (n=32), nephrology (n=5) and intensive care unit (n=5). The most common indications were: polyradiculoneuropathies (53%), myasthenia gravis (17%) and Guillain-Barré syndrome (12%). RESULTS The median TPE procedure per patient was 2.3 (range, 1-10). In the majority of patients, vascular access was provided by puncture of two large, durable peripheral antecubital veins. The procedures were performed with the "Haemonetic Ultralight" discontinuous flow cell separator devices. Citrate solution was used as an anticoagulant in all cases. The substitution fluids most often used in our unit are Albumin 20% solution (92 times), Albumin 4% (10 times) and fresh frozen plasma (twice). Seventy five percent of the patients showed improvement, 7% remained the same and 18% worsened. Thirteen adverse reactions were recorded. CONCLUSION The creation of a national registry by the local society is a vital move to improve TPE practice in our country.
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Affiliation(s)
- I Tazi
- Centre Régional de Transfusion Sanguine, Casablanca, Morocco.
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House AA, Ronco C. Extracorporeal blood purification in sepsis and sepsis-related acute kidney injury. Blood Purif 2008; 26:30-5. [PMID: 18182792 DOI: 10.1159/000110560] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Sepsis-related acute kidney injury (AKI) is an important complicating feature of sepsis, and is associated with greater complexity of care and higher mortality. Until recently, AKI lacked a standard, widely accepted definition, rendering it difficult to compare previously published strategies to prevent, recognize and treat this entity. Recently, the RIFLE classification of AKI has been developed, and confirmed in observational studies to be associated with subsequent morbidity and mortality. The management of sepsis-related AKI is evolving with new basic discoveries and ongoing translational clinical research, and will likely include nephroprotective strategies to protect kidneys in patients at risk, early recognition and amelioration of renal damage and pharmacological interventions to minimize injury and promote recovery. Furthermore, extracorporeal blood purification (EBP) has an important role to play, not only in the replacement of certain aspects of renal organ function such as acid-base/electrolyte homeostasis and extracellular fluid volume, but also in an immunomodulatory fashion. As a therapy that has the potential to influence the course of disease in sepsis, EBP in sepsis and sepsis-related AKI is the subject of this review.
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Affiliation(s)
- Andrew A House
- Division of Nephrology, University Hospital, London Health Sciences Centre, London, Ontario, Canada.
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Weinstein R. Therapeutic apheresis in neurological disorders: A survey of the evidence in support of current category I and II indications for therapeutic plasma exchange. J Clin Apher 2008; 23:196-201. [DOI: 10.1002/jca.20178] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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