Feasibility of therapeutic plasma exchange-based combination therapy in the treatment of acquired hemophilia A: A retrospective 6 case series

Poor availability and a lack of affordability of bypassing agents (recombinant activated factor VII and activated prothrombin complex concentrate) in west China prompted us to investigate an alternative cost-effective combination therapy. We aimed to explore the feasibility of therapeutic plasma exchange (TPE)-based combination therapy in the treatment of acquired hemophilia A (AHA).We retrospectively investigated the clinical features of AHA in 6 patients who were treated with a combination of TPE, corticosteroids, and rituximab in our department for 9 years between January, 2011 and December, 2019.We examined 1 male and 5 female patients. The median age at diagnosis of AHA was 51 years (18-66 years). In all patients, FVIII activity levels were low (median: 1.5%; 1-3%), FVIII inhibitor titers were high (median: 24.5 BU/mL; 13.2-48.6 BU/mL), and activated partial thromboplastin time was markedly prolonged (median: 99.4 s; 60.9-110.1 s). They underwent 2 to 8 cycles of plasma exchange and were given varying combinations of dexamethasone, methylprednisolone, prednisone, and rituximab. After TPE bleeding gradually stopped, and activated partial thromboplastin time decreased. After 3 months of treatment, FVIII inhibitors completely disappeared.TPE when combined with corticosteroids and rituximab, as adjunctive immunosuppressive agents, may be an effective and reliable treatment for AHA. When there is no alternative, intensive first-line treatment including TPE may be lifesaving.

Clinical Features and Outcomes of Acute Kidney Injury in Patients Infected with COVID-19 in Xiangyang, China

BACKGROUND

In December 2019, pneumonia associated with COVID-19 has spread from Wuhan to other areas in China. In the present study, we aimed to further clarify the clinical features and outcomes of acute kidney injury (AKI) in patients infected with COVID-19 in Xiangyang, Hubei, China.

METHODS

All confirmed cases of COVID-19 with AKI in Xiangyang Central Hospital from January 22 to May 31, 2020, were included in this retrospective study. Data of epidemiological, clinical, laboratory, radiological tests, treatment, complication, and outcomes were collected and analyzed. Patients were divided into intensive care unit (ICU) group and isolation ward (non-ICU) group.

RESULTS

Of the total patients, 33.3% in the non-ICU group and 85.7% in the ICU group had chronic diseases. In addition, 85.7% of patients in the ICU group died. The most common symptoms were fever, cough, and fatigue. The lymphocyte count in the ICU group was significantly reduced compared with the non-ICU group. The chest computed tomography (CT) images appeared showed multiple mottles and ground-glass opacity. Strip shadow could be found in chest CT images of some recovered patients. All patients received antiviral treatment. Most patients in the ICU group were given methylprednisolone, immunoglobulin, antibiotics, and mechanical ventilation and 35.7% of patients in the ICU group received continuous renal replacement therapy.

CONCLUSIONS

Elderly with chronic comorbidities were more susceptible to COVID-19, showing a higher mortality rate due to multiple organ damage, and 35.7% of patients with AKI in ICU received renal replacement therapy. Moreover, part of the cured patients might need additional time to recover for poor lung function.

Lower number of plasma exchange sessions and glomerular filtration rate decline are associated with second relapses in patients with myasthenia gravis

The aims were to determine the impact of dysphagia and glomerular filtration rate (GFR) in the prediction of myasthenia relapse and analyse whether different number of plasma exchange sessions could prolong the time before future relapse.This was a retrospective, longitudinal follow-up study with 60 enrolled patients. The patients were followed-up for a total of 50 months.Patients without relapses had significantly higher GFR and higher number of plasma exchange sessions when compared to patients with relapses. Mean time before next myasthenia relapse was significantly longer in patients with GFR ≥ 60 mL/min. Time before next and number of following myasthenia relapses were significantly higher in patients with symptoms of dysphagia.Decline in GFR levels is strongly associated with the presence of dysphagia and independently impacts the onset of myasthenia relapses. Timely initiation of plasmapheresis therapy and adequate hydration of patients with prolonged dysphagia should be one of the treatment goals for clinicians treating this disease.

Variation in the Treatment of Children Hospitalized With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis in the US

OBJECTIVE

There are few reports on the treatment of antineutrophil cytoplasmic antibody-associated vasculitis (AAV) in children. This study characterizes the use of cyclophosphamide, rituximab, and plasma exchange in children hospitalized with AAV in the US.

METHODS

We conducted a retrospective cohort study of children hospitalized with AAV from 2004-2014 utilizing an administrative and billing database from 47 tertiary care pediatric hospitals. All patients had an International Classification of Diseases, Ninth Revision, Clinical Modification discharge code of 446.4 and ≥1 charge for glucocorticoids. Treatment receipt was determined using billing data. Mixed-effects logistic regression was used to evaluate factors associated with the likelihood of receipt of each of the 3 treatments.

RESULTS

During the 11-year study period there were 1,290 admissions for 393 children. The median age at index admission was 14.6 years, and 61% were female. Dialysis or mechanical ventilation was required by 16% and 17% of the children, respectively. The median length of stay was 9 days. The percentages of children receiving cyclophosphamide, rituximab, or both were 57%, 21%, and 10%, respectively, and 22% received plasma exchange. Mechanical ventilation was associated with the receipt of cyclophosphamide and plasma exchange, but not rituximab. There was an increasing trend in the use of rituximab over time during the study period (P < 0.05), and a decreasing trend in the use of cyclophosphamide (P < 0.05). Treatment use varied significantly between hospitals, especially for plasma exchange.

CONCLUSION

The treatment of children with severe AAV is shifting from cyclophosphamide to rituximab, and their need for dialysis, mechanical ventilation, and prolonged hospitalization remains common. Use of plasma exchange is highly variable.

Acute Flaccid Myelitis of Unknown Etiology in California, 2012-2015

IMPORTANCE

There has been limited surveillance for acute flaccid paralysis in North America since the regional eradication of poliovirus. In 2012, the California Department of Public Health received several reports of acute flaccid paralysis cases of unknown etiology.

OBJECTIVE

To quantify disease incidence and identify potential etiologies of acute flaccid paralysis cases with evidence of spinal motor neuron injury.

DESIGN, SETTING, AND PARTICIPANTS

Case series of acute flaccid paralysis in patients with radiological or neurophysiological findings suggestive of spinal motor neuron involvement reported to the California Department of Public Health with symptom onset between June 2012 and July 2015. Patients meeting diagnostic criteria for other acute flaccid paralysis etiologies were excluded. Cerebrospinal fluid, serum samples, nasopharyngeal swab specimens, and stool specimens were submitted to the state laboratory for infectious agent testing.

MAIN OUTCOMES AND MEASURES

Case incidence and infectious agent association.

RESULTS

Fifty-nine cases were identified. Median age was 9 years (interquartile range [IQR], 4-14 years; 50 of the cases were younger than 21 years). Symptoms that preceded or were concurrent included respiratory or gastrointestinal illness (n = 54), fever (n = 47), and limb myalgia (n = 41). Fifty-six patients had T2 hyperintensity of spinal gray matter on magnetic resonance imaging and 43 patients had cerebrospinal fluid pleocytosis. During the course of the initial hospitalization, 42 patients received intravenous steroids; 43, intravenous immunoglobulin; and 13, plasma exchange; or a combination of these treatments. Among 45 patients with follow-up data, 38 had persistent weakness at a median follow-up of 9 months (IQR, 3-12 months). Two patients, both immunocompromised adults, died within 60 days of symptom onset. Enteroviruses were the most frequently detected pathogen in either nasopharynx swab specimens, stool specimens, serum samples (15 of 45 patients tested). No pathogens were isolated from the cerebrospinal fluid. The incidence of reported cases was significantly higher during a national enterovirus D68 outbreak occurring from August 2014 through January 2015 (0.16 cases per 100,000 person-years) compared with other monitoring periods (0.028 cases per 100,000 person-years; P <.001).

CONCLUSIONS AND RELEVANCE

In this series of patients identified in California from June 2012 through July 2015, clinical manifestations indicated a rare but distinct syndrome of acute flaccid paralysis with evidence of spinal motor neuron involvement. The etiology remains undetermined, most patients were children and young adults, and motor weakness was prolonged.

Therapeutic plasma exchange in clinical practice: long-term single centre experience

Therapeutic plasma exchange (TPE) is a powerful tool in the treatment of a whole host of diseases and there is hardly any organ for which TPE has not been shown to have some beneficial effects. In most instances, TPE is indicated only as a last resort treatment if all conservative measures have failed. However, there are lifethreatening conditions where TPE is the primary mode of acute treatment. Results from recent randomized prospective controlled trials caused a narrowing of the spectrum of indications for use of TPE, while advances in the various fields of medicine and technology have enabled wider clinical application of this procedure and generated several new indications. To define the current role of TPE, we retrospectively analysed changes in indications for TPE in our database, that contains information on all TPEs conducted during 27 years at University Hospital Centre Zagreb (a national referral centre for therapeutic apheresis, which covers approximately 90-95% of all TPEs performed in Croatia). The number of patients, including children and elderly people) who underwent this procedure and TPEs increased several-fold over 27 years of follow-up despite changes in the pattern of indications and the emergence of new, more selective therapeutic options (LDL-apheresis, immunoadsorption, etc.). With wider application of TPE, fear of its complications have diminished, which may be the reason for the more frequent treatment of very young children and very old patients. Our results derived from a large number of treatments indicate that TPE is a relatively safe method of treatment, providing it is carried out by experienced staff, and used for appropriate indications with all necessary precautions. Despite the development of more selective methods, TPE is still a widely applicable and useful procedure, possibly experiencing a renesance in this century.

Living conditions and palliative care needs among end-of-life former commercial plasma donors affected with HIV/AIDS in rural Henan of China

OBJECTIVE

China began providing antiretroviral therapy to people living with HIV/AIDS (PLWHA) in 2003. This study was to investigate the living conditions, including quality of life and happiness, and need for palliative care of end-of-life PLWHA in rural Henan.

METHODS

One hundred end-of-life AIDS patients were selected from Weishi, Zhenping and Tanghe counties in Henan, using convenience sampling. The World Health Organization Quality of Life for HIV (WHOQOL-HIV) BREF Chinese Version was used to measure the quality of life and the Memorial University of Newfoundland Scale of Happiness (MUNSH) was employed to measure subjective welfare. Qualitative interviews and focus group discussions were undertaken to learn about the palliative care provided and the specific needs of the end-of-life patients.

RESULTS

Patients' overall quality of life was moderate (12.62±1.97). Highest scores were in the spirituality/religion/personal beliefs, higher than the average scores in the Chinese population (P<0.01), while psychological (13.58±2.06) and environment (12.50±3.28) domain scores were similar to the latter (P>0.05). Both independence (12.15±2.15) and physiological (14.04±3.16) domain scores were lower than the average of the people living with HIV/AIDS in other studies (P<0.01); however, all were in the moderate range. The average MUNSH score was 21.00±6.20, which was also moderate. The in-depth interviews indicated that the Henan Provincial Government's policy of treatment and care had a beneficial impact on end-of-life AIDS patients, although the care components could be improved.

CONCLUSIONS

Living conditions of the end-of-life AIDS patients were moderate, and the HIV/AIDS palliative care model used was beneficial to them. Care could be improved by assisting the family unit as a whole.

[Reducing the frequency of fresh frozen donor plasma transfusion on the basis of the results of thromboelastographic study in neurosurgical patients with intraoperative blood loss]

The paper gives the results of a study of the time course of changes in the major laboratorily determined hemostatic parameters, as well as the main characteristics of a thromboelastographic curve in 95 neurosurgical patients who developed significant intraoperative blood loss at surgery. The patients were divided into 2 comparable groups: 1) a decision on fresh frozen donor plasma transfusion was taken only on the basis of laboratory parameters; 2) this was done on the basis of thromboelastographic data. In Group 2, the frequency of fresh frozen donor plasma transfusion proved to be 4 times less than that in Group 1. The use of thromboelastography to evaluate the hemostatic system during operations with a significant blood loss volume permits a reduction in the frequency of fresh frozen donor plasma, without deteriorating the results of treatment.

The diagnosis and treatment of HIV-infected children in China: challenges and opportunities

BACKGROUND

HIV-infected children in China have not been well studied. This national survey describes the demographic characteristics and the associated diagnostic and antiretroviral treatment (ART) efforts directed toward surviving HIV-infected children.

METHODS

A cross-sectional study was conducted in the 6 provinces with the highest HIV prevalence: 4 former plasma donation (FPD) provinces and 2 intravenous drug use (IDU) provinces. A survey on demographics and treatment-related issues was distributed to the parents or guardians of all living HIV-infected children identified through the national case reporting system. Descriptive and bivariate analyses were performed on completed surveys.

RESULTS

Six hundred ninety-two (62.4%) of the total 1108 surveys were returned, and 650 were eligible for analysis. The average age in FPD provinces (mean +/- SD: 8.1 +/- 3.2 years) was significantly older than in IDU provinces (mean +/- SD: 5.4 +/- 2.2 years; P < 0.001). The average lag time from the probable date of transmission to a diagnosis for patients with mother-to-child transmission (MTCT) was 6.7 +/- 3.1 years in the FPD provinces and 4.7 +/- 1.9 years in the IDU provinces (P < 0.001). On the basis of the CD4 cell count or World Health Organization staging, 29.8% (144 of 484) of children from all 6 provinces who were not on ART needed it.

CONCLUSIONS

This first national pediatric survey indicates that the age and time required for diagnosis were greater in HIV-infected children from FPD provinces compared with those from IDU provinces. In addition, this survey highlights the prolonged delay in the diagnosis and initiation of ART for children in China. Aggressive efforts to identify HIV-positive pregnant women, scale up prevention of MTCT activities, and expand early diagnosis and treatment are urgently needed.

What are the indications for plasma exchanges in autoimmune diseases?: The registry of the Société Française d’Hémaphérèse

The use of plasma exchange (PE) in the autoimmune diseases is encouraged in France. Since 1990, the national registry of PE allows an analysis of the evolution of the coverage of these pathologies. The variation of the number of patients treated by PE is correlated in respect to the results of the therapeutic studies. After a decrease of PE activity in these indications during the 90s, one observes a new increase of the patients treated because of the validation of new indications. Autoimmune diseases represent the third cause of morbidity in developed countries, with a global prevalence of 5%, and concerns four groups of pathologies of organs or systems (neurology, haematology, nephrology and vasculitis). In 1976, Lockwood demonstrated the place of plasma exchanges (PE) in Goodpasture's syndrome [Lockwood CM, Rees AJ, Pearson TA, Evans DJ, Peters DK, Wilson CB. Immunosuppression and plasma exchange in the treatment of Goopasture's syndrome. Lancet 1976;1(7962):723-6. [1]], with a significant decrease of antibodies during large volume exchanges. In the 80s, several prospective studies began to estimate the efficiency of PE in other autoimmune diseases. The national registry of the Société Française d' Hémaphérèse, has collected the epidemiological and technical data of PE since 1985. This work analyses the evolution of the validated indications, between 1990 and 2005 in France.

Therapeutic apheresis in the Republic of Macedonia - our five years experience (2000-2004)

Membrane plasma exchange (PE) is a mode of extracorporeal blood purification. Since 1985 membrane PE has been in regular use at the Department of Nephrology, Medical Faculty of Skopje, R.Macedonia. In this paper we report on five years (2000-2004) of single centre plasma exchange activity. We performed 540 PE treatments (108 PE/per year) on 99 patients. The M/F ratio was 40/48. The patients underwent a median of 5.45 procedures (range, 1-16). The treated patients were from different Departments. Protocols for PE depend on the disease and its severity. PE were performed 2-4 times weekly using Gambro PF 2000 N filters with an adaptation of the Gambro AK10 dialysis machine or with the Gambro Prizma machine (2 cases). Blood access was achieved through femoral vein. Substitution was made with fresh frozen plasma and/or with 20% human albumin combined with Ringer's solution. An average amount of 2150 ml plasmafiltrate per treatment (respectively 30 to 40 ml plasmafiltrate/kg body weight) was eliminated. Most therapeutic procedures were performed on patients from the Department of Neurology. 63.6% of all patients were referred for Myasthenia gravis and the Guillian Barre syndrome. The total number of procedures per year has remained fairly stable, corresponding to a median of 5.4 treatments/100 000 inhabitants. We observed hypocalcaemia in 8% of the patients, urticarial reactions in 7.3%, pruritic reactions in 12%, and hypotension/headache in 6.8%. No major procedural complications were seen.

Transfusion increases the risk of postoperative infection after cardiovascular surgery

BACKGROUND

Because of the immunomodulatory effects of transfusion, we attempted to identify factors associated with blood product use and determine the association of transfusion quantity with postoperative infection.

STUDY DESIGN

We studied total perioperative transfusion of blood products for 15,592 cardiovascular operations performed from July 1998 to May 2003. Infection end points were septicemia/bacteremia (n=351, 2.2%) and superficial (n=353, 2.3%) and deep (n=212, 1.4%) sternal wound infections. Factors associated with blood product administration were used to form balancing scores to adjust for differences in patient characteristics among those receiving and not receiving blood products.

RESULTS

Fifty-five percent of patients received packed red blood cells (RBC), 21% received platelets, 13% got fresh frozen plasma (FFP), and 3% got cryoprecipitate. Factors associated with RBC use included older age, female gender, higher New York Heart Association class, lower hematocrit, reoperation, and longer cardiopulmonary bypass time--all indicative of higher-risk patients. The more RBC units transfused, the higher was the occurrence of septicemia/bacteremia (p < 0.0001) and superficial (p=0.0007) and deep (p < 0.0001) sternal wound infection. Use of FFP (septicemia/bacteremia) and platelets (septicemia/bacteremia and deep sternal wound infection) mitigated against this association only slightly.

CONCLUSIONS

Blood products tended to be used in the sickest patients. But after accounting for this, risk of infection increased incrementally with each unit of blood transfused. Although cause and effect cannot be established, results suggested that blood product transfusion is an independent risk factor for postoperative infection in cardiac surgical patients, blood products are more likely to be used in the sickest patients, and no amount of blood loss treated by transfusion is innocuous.

Apheresis activity in Venezuela

Interest for apheresis activity has been growing in Venezuela. In 1976 there were only a few devices; in 2003, 80 apheresis machines performed 27,675 donor apheresis procedures and 547 therapeutic procedures countrywide. We report the activity at the Metropolitan Blood Bank (the largest one of the country) in the period 1999-2003: 597 therapeutic procedures were performed in 171 patients, during 212 crisis episodes. The average age was 38 +/- 16 years, 65% male and 35% female. Most of the therapeutic procedures were therapeutic plasma exchange for hematology diseases (mainly thrombotic thrombocitopenic purpura and hemophilia inhibitors), including 184 therapeutic procedures with the Autopheresis-C (Baxter Healthcare Corp., Deerfield, IL). Most common adverse effects (3.9%) were hypotension and allergic reactions to the plasma.

The Oklahoma Thrombotic Thrombocytopenic Purpura-Hemolytic Uremic Syndrome Registry: a program for patient care, education and research

The Oklahoma Thrombotic Thrombocytopenic Purpura-Hemolytic Uremic Syndrome (TTP-HUS) Registry was created by collaboration of the Oklahoma Blood Institute and the Colleges of Medicine and Public Health of the University of Oklahoma Health Sciences Center, combining their respective strengths of community service, patient care, education, and clinical research methodology. The organization of the Registry is based on the fundamental principles of patient-oriented research: 1) all consecutive patients are identified at a uniform time early in the course of their disease; 2) analysis of clinical data requires quantitative and reproducible definitions; 3) patient follow-up is complete; and 4) therefore the data are generalizable to community practice. A summary of 15 years experience with 301 consecutive patients is presented. Some of these results and interpretations are different from other case series. These differences emphasize the distinct perspective of the Registry that includes all patients in the community who have had a clinical diagnosis of TTP or HUS and for whom plasma-exchange treatment was requested. The Oklahoma TTP-HUS Registry provides educational and research opportunities, in addition to improved patient care, and serves as a model for productive collaboration of community blood centers and universities.

Therapeutic plasma exchange in a single center: Ibni Sina experience

BACKGROUND

The number of therapeutic procedures is increasing steadily year by year with growing collaboration of departments other than Hematology. In the aim to demonstrate our single center activity we analyzed our data since four years.

METHODS

Between years 1998 and 2001, 658 therapeutic plasma exchange (TPE) procedures were performed on 158 patients. Median age and male/female ratio were 37 (range, 15-87) and 80/78, respectively. Main indications were myastenia gravis (n=55, 34%), TTP (n=13, 8.5%), post ABO mismatched allogeneic hematopoietic cell transplantation aregeneratoric anemia (n=6, 7.5%), progressive systemic sclerosis (n=10, 6.5%), multiple myeloma (n=10, 6.5%), Gullian Barre Syndrome (n=9, 5.9%), multiple sclerosis (n=7, 4.6%), Waldenström Macroglobulinemia (n=5, 3.4%), polymyositis (n=4, 2.7%), sepsis and disseminated intravascular coagulation (n=4, 2.7%). Departments who referred the majority of the patients for TPE were neurology (n=199), hematology (n=153), immunology (n=78), intensive care unit (n=78) and thorax surgery (n=51).

RESULTS

The median TPE procedure per patient was 4 (range, 1-50). All the procedures were performed on continuous flow cell separators and median plasma volume processed per cycle was 2471 ml (range 436-5000). The replacement fluids used were 3% hydroxyethylstarch (HES) (24%), 5% albumin (35%), fresh frozen plasma (25%), and HES and albumin (16%). HES was tolerated well even as a sole replacement fluid with acceptable minor side effects. In three patients with progressing hypoalbuminemia HES was replaced or combined with 5% albumin. Close monitoring of serum albumin and fibrinogen levels after repeated procedures is mandatory.

CONCLUSION

In our four years of TPE experience we have increased our collaboration with other departments. 3% HES+/-5% Albumin is a feasible, well tolerated and cost effective replacement fluid combination especially for short-term plasma exchange therapy.

Current Status of Therapeutic Plasma Exchange in Korea

A nationwide survey on the status of plasma exchange in Korea was performed during the 2 year period 2001-02. Data from 496 patients were collected from 15 major hospitals. The most common indication was myasthenia gravis (15.3%), followed by thrombotic thrombocytopenic purpura (14.5%) and hemolytic uremic syndrome (9.7%). Clinical improvement was noted in 70.1% of the 415 cases. Plasma exchange by centrifugation alone accounted for 92.4%. Postcentrifugal filtration was carried out in 5.6% and double filtration in 2.0% of treatments. The most common instruments for the centrifugation were Cobe Spectra (71.3%) and Fenwal CS3000 (15.8%). Filtration was performed by either Kuraray KM8300 or Kuraray KM8800. The overall frequency of complications was 11.1% (293/2647 cases), of which symptomatic hypocalcemia was the most common (2.3%).

Is there a need for a national or a global apheresis registry?

Indications for apheresis may vary and more than 45 different diagnoses have been reported from various countries. New devices are being developed and, in the beginning their clinical implications and use are limited to detect rare but important side effects. However, to achieve more reliable information on the effects and side effects we need more extensive sampling of data. Collection of such data is considered a safety and quality issue in several countries. However, data is still limited and little is known about therapeutic apheresis practised around the world including the incidence and pattern of adverse events. The establishment of national registries and analyses of data on a global level therefore seems important. Thus the World Apheresis Association (WAA) has initiated a global apheresis registry for therapeutic procedures and collection of e.g., stem cells. The WAA registry is Internet based and the site is at www.iml.umu.se/medicin. A login code to test the registry is needed (AL61TMS). This report deals with the aim of a global registry as well as some comparative data regarding findings of the Canadian, French and Swedish registries.

Plasma exchange in France: Epidemiology 2001

The French plasma exchange registry created in 1985 lists the indications, techniques and complications of the French therapeutic haemapheresis. In 2001 it contains the data of more than 16,700 patients for a total of 153,641 sessions. The indications concern five groups of pathologies (neurology, haematology, nephrology, vasculitis, and endocrinology). Until 2000, the neurology represented the most important group but the use of the high dose IgIV for Guillain-Barre and myasthenia gravis decreased the indications. The haematology became most important group treated because of the increase of the TTP and HUS number treated. The endocrinology (familial hypercholesterolemia) represents at present 10% of the patients treated for 18.7% of the sessions. The vascular access little changed since 1985, the peripheral venous access being the most used. The plasma substitution initially based on the albumin alone was gradually replaced by an association albumin macromolecules, in particular hydroxyethylstarch since 1990. After the observation of the side effects due to starches we observed an increase of the albumin alone use. The immediate complications decreased in half in 15 years. The French plasma exchange registry is the largest world database of haemapheresis with the cooperation of about 80 centres, allowing numerous scientific studies.

Therapeutic apheresis in Sweden: update of epidemiology and adverse events

The indications of apheresis have changed over time due to results from various studies as well as the innovation of new techniques and ideas. To get an overview of the indications used for apheresis by colleagues elsewhere, data from registries are valuable. In addition, registries can be used for detection of severe adverse events as well as extent of adverse events in various types of treatment. To have a basis for statistical calculations, apheresis units need to be very large or centralisation of data needs to be performed. Data from more than 20000 procedures show that in about 4.3% of occasions adverse events and other problems will develop. Interruption of the procedure was done in 1%, most frequently a plasma exchange. Technical problems can be expected more frequent when performing LDL apheresis and immunoadsorption. Severe adverse events needing medication or interruption of the treatment, such as hypotension and arrhythmia, will develop in about 1% of the procedures. Such an episode occurs more often in patients with TTP/HUS and Guillain-Barré syndrome than in hypercholesterolemia, hyperviscosity syndrome or septic shock/MODS. The non-severe adverse events have increased over time. The results will provide focus in analyses for the reduction of such adverse events.

[Therapeutic hemapheresis]

BACKGROUND

This is the first survey of therapeutic hemapheresis in Norway. The purpose was to collect data from all Norwegian dialysis and blood units performing hemapheresis treatment and stem cell collection for comparison with Swedish data.

MATERIALS AND METHODS

Questionnaires were sent to all regional and central hospitals in Norway including two specialized centres for stem cell apheresis. The questions included the number of hemapheresis procedures, patients, and indications.

RESULTS

All units responded to the questionnaire. There were 17 dialysis units; seven blood units and two special units who performed 2,141 procedures. 12 units did not carry out any hemapheresis treatment at all. There were five stem cell collections per 100,000 inhabitants and 42.5 therapeutic apheresis procedures per 100,000 inhabitants.

INTERPRETATION

Hemapheresis treatment is performed in all Norwegian health regions. The indications are quite similar to those reported from Sweden except for stem cell collections and erythrocytaphereses. The dominance of the dialysis units in the total number of procedures performed and the prominent use of filtration techniques are special features of the Norwegian practice of apheresis.

Therapeutic plasma exchange: an underutilized therapeutic modality?

Since its clinical availability approximately 25 years ago, therapeutic plasma exchange (TPE) has become recognized as appropriate primary therapy for many diverse medical conditions. In some aspects TPE has been constrained in its use according to schedules of efficacy. Expansion of TPE to other indications is likely once attention is focused on its ability to enable patients to avoid potentially toxic pharmacologic interventions if employed as a chronic therapy, and especially when it is accepted that adjunctive use, not only a curative role, is a valuable use of this therapeutic modality.

Incidence of allergic reactions with fresh frozen plasma or cryo-supernatant plasma in the treatment of thrombotic thrombocytopenic purpura

Plasma replacement for thrombotic thrombocytopenic purpura (TTP) is accomplished with various plasma products. This study sought to determine the incidence of allergic reactions with FFP or CPP as replacement in therapeutic plasma exchange (TPE). Forty-one TTP patients were identified retrospectively who received TPE replacement with either FFP (n=21) or CPP (n=20). Anti-histamine was administered prophylactically following the initial occurrence of an allergic reaction (urticaria, respiratory distress, or anaphylaxis with hypotension). Fifty-one allergic reactions occurred in 65.8% of patients. Urticaria comprised 49 of 51 (96%) of reactions and respiratory distress the remaining 4%. No anaphylaxis occurred. Nineteen urticarial reactions occurred in 50% of CPP recipients compared to 71% of FFP recipients (P=0.28). Anti-histamine breakthrough occurred in 36.3% of patients who experienced a previous allergic reaction with CPP and 37.5% with FFP (P=1.0). The overall risk of allergy per unit of plasma was 1.37% (1.23 % CPP, 1.48% FFP), comparable to estimates in non-TTP recipients. The median number of donor exposures preceding the first allergic reaction was 35 and 32, CPP and FFP, respectively (P=0.63). The mean volume of plasma transfused prior to reaction was 9,883 mL for CPP and 9,348 mL for FFP (P=0.85). Neither product was advantageous in preventing allergic complications. Because of the large volume, the number of donor exposures, and prolonged duration of therapy, allergic reactions to plasma are common (65.8%) in the treatment of TTP.

Treatment of steroid-unresponsive tumefactive demyelinating disease with plasma exchange

The authors describe a patient with an isolated, gadolinium-enhancing, biopsy-proven focus of tumefactive demyelination. There was marked clinical improvement with plasma exchange after failure of high-dose i.v. corticosteroids. The post-treatment clinical course correlated with decreasing enhancement and lesion size on MRI. This patient's rapid clinical and MRI response suggests that plasma exchange may be beneficial in this disorder, and could perhaps serve as a diagnostic tool to avoid the need for brain biopsy.

14 years of therapeutic plasma exchange in France

The French Registry for plasma exchange (PE) was set up in 1985. For 14 years it has allowed analysis of the techniques used along with the indications and complications. Recent analysis shows a slight fall in activity as some studies have ended, while the neurological disorders remain the most frequent indications for PE. The important changes observed over the years are the increased use of the centrifugation technique, the development of plasma and whole blood treatment and plasma substitution using a mixture of albumin and pentastarch. The French Registry for PE is the largest such database which, along with the Canadian Registry for therapeutic hemapheresis, allows both retrospective and prospective studies.

Adverse events and problems in therapeutic hemapheresis. A report from the Swedish registry

BACKGROUND

Since 1996 adverse events (AE) in therapeutic apheresis (TA) have been more extensively registered in Sweden. This report analyzes the extent and relation of AEs to procedures and diagnoses.

MATERIALS AND METHODS

Reporting of TA performed in Sweden was centralized. A separate system for the registration of AE in TA was established and the data received were entered into a central database for registration and analyses. Fifteen of all 35 apheresis units reported both TA and AE during 1996-1999. These centers performed 75% of all TA procedures. Adverse events included medical symptoms, vascular access problems, technical and other problems.

RESULTS

More than 14,000 procedures were registered during the observation period. No fatalities occurred. AEs occurred in 3.7% (1996), 4.6% (1997), 4.2% (1998) and 4.4% (1999) of procedures. Interventions during the adverse event were performed in about 65% of the events. Apheresis procedures were interrupted due to an adverse event in about 1%. Adverse events occurred in 5.6% of plasma exchanges, 1.9% of plasma modulations and 6.8% of cytapheresis procedures. Paresthesia was registered in 22% and hypotensive events in 20.5%. Other more frequent symptoms were urticaria (14.4%), shivering (7.4%) and nausea (7.4%). AEs were most frequent in patients with Goodpasture's syndrome (12.5%), TTP/HUS (10.5%) and GuillainBarré syndrome (11.0%).

CONCLUSION

AEs are few, often mild and less common in plasma modulation than plasma exchange. AEs are more frequent during TA of patients with certain diagnoses such as TTP/HUS.

Apheresis registry in Sweden: scope, techniques and indications for treatment. A report from the Swedish apheresis study group

Registries of therapeutic apheresis can be used to evaluate changes in technology, clinical indications and applications over the years. This study reports data collected prospectively and voluntarily in Sweden during 1993-1999. A total number of 40 apheresis units have been performing therapeutic apheresis procedures: 16 blood centers, 20 dialysis units, two intensive care units, one hematology ward and one hemotherapy unit. The registry includes a median of 92%) of the centers for therapeutic apheresis in Sweden during the years and in 1999 there were 31 active units in 26 hospitals. The total numbers of procedures per year have remained fairly stable corresponding to a median of 46 treatments/ 100,000 inhabitants, and in 1999 4084 procedures were performed. The number of plasma exchanges has decreased, but LDL-apheresis and immunoadsorption procedures have increased over the years. 70% of the patients have been referred for 12 indications. A significant decline was found for patients with SLE and Guillain Barres syndrome. The use of extracorporeal photo-chemotherapy has increased over the years, and 3 indications include >75$ of the patients. There has been an adaptation to the experience learned by different studies. The number of collections of hematopoietic progenitor cells is about 9/100,000 inhabitants, and in 1999 821 collections were performed. The use of allogeneic donors is increasing. The extent of therapeutic apheresis in Sweden was compared to other countries on the basis of published data. In Sweden, the extent of therapy is two- to three-fold to that for Canada and France.

Predictable recovery from myasthenia gravis crisis with plasma exchange: thirty-six cases and review of current management

Adult, acquired, idiopathic, autoimmune myasthenia gravis has a well-characterized IgG anti-acetylcholine striated-muscle receptor antibody. Removal by plasma exchange is effective, established therapy to augment anti-cholinesterase and immunosuppressive therapy and is the treatment of choice for myasthenia gravis crisis. We report 36 consecutive patients referred and accepted for plasma exchange, 32 of whom were in or entering myasthenia crisis, over a 10 year period. An average of 7.8 (range 1 to 16) plasma exchange procedures were done, with uniform, significant improvement, including extubation of 13 in myasthenic crisis and discharge from hospital in all. We conclude that this is the best treatment for myasthenia gravis crisis in hospital. From recent cases, most, if not all, crises can be prevented by IVIgG or plasma exchange as out-patients with use of corticosteroid and or azathioprine.

National survey of hemapheresis practice in Turkey (1998)

The Turkish Apheresis Group has maintained a national registry for apheresis activities since 1997. The hemapheresis practice of Turkey in 1998 is summarized in brief detail in this article. A total of 30, 136 apheresis procedures were performed at 31 different apheresis centers. At 10 centers, 145 peripheral blood stem cell (PBSC) apheresis were performed on 82 patients in allogeneic setting and at 17 centers, 981 PBSC apheresis were performed on 271 patients in autologous setting. Frequently observed adverse effects during PBSC apheresis were mild tremor and chills, paresthesia and nausea in 15% of the patients and donors. Vascular access complications, particularly observed in autologous setting due to central venous catheters were encountered in 10% of the procedures. Eight hundred and sixty-nine therapeutic plasma exchange procedures were performed at 21 centers on 172 patients, most commonly for neurological disorders and thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS). Therapeutic cytapheresis procedures like leukapheresis, plateletapheresis and erythrocyte apheresis were performed especially for cytoreduction in myeloproliferative disorders. A total of 204 cytapheresis procedures (66% leukapheresis, 33% plateletapheresis and 1% erythrocytapheresis) were performed on 134 patients in 15 centers. Donor plateletapheresis was the most used apheresis procedure, reaching a total of 28.016 in 1998. Many university hospitals and a few state hospitals are performing above-mentioned apheresis procedures with great success and acceptable side effects. According to these data we are planning prospective trials and will establish National Standards of Practice.

Apheresis registry in France: indications, techniques, and complications. French Registry Study Group

The French Registry for Plasma Exchange (PE) was set up in 1985. For 13 years it has allowed for the analysis of the techniques used, along with the indications and complications. After a decrease in the number of participating centers due to the heaviness of the data collection mode, the telematic network created in 1991 led to a new increase in participants from 26 in 1990 to 69 in 1998. Follow-up shows a slight fall in activity since some protocols ended, while the neurological pathologies remain the most frequent indicators. The important modifications observed over the years are the increase of the centrifugation technique, the development of plasma treatment, and the plasma substitution by an association of albumin-pentastarch. The French Registry for plasma exchange is the largest data base dealing with therapeutic hemapheresis. The registry set-up through the internet is the first step toward an international data base.

Therapeutic plasma exchange: an update from the Canadian Apheresis Group

In 1997, the Canadian Apheresis Group reviewed data on 103,416 plasma exchange procedures that had been collected since 1980. Although the number of plasma exchanges gradually increased (from 3189 to 8208 per year), the pattern changed. In 1981, the five most frequent indications for plasma exchange resulted in 55% of all such procedures; by 1997, the five most frequent indications for plasma exchange resulted in 81.1% of all such procedures. During this period, three conditions that were originally among the most frequent indications for plasma exchange became among the least frequent. This paper reviews the published evidence that supports or refutes the use of plasma exchange in the category of the five most frequent indications from 1981 to 1997: thrombotic thrombocytopenic purpura, myasthenia gravis, chronic inflammatory demyelinating polyneuropathy, Waldenstrom macroglobulinemia, the Guillain-Barre syndrome, rheumatoid arthritis, systemic lupus erythematosus, and multiple sclerosis. For most disorders, use of plasma exchange procedures is correlated with published evidence, and the changing patterns of plasma exchange use by members of the Canadian Apheresis Group reflect published evidence. Annual center-by-center reviews of use of plasma exchange may also have influenced practice patterns.

Role of replacement fluids in the immediate complications of plasma exchange. French Registry Cooperative Group

OBJECTIVE

Comparison of side effects (fever shivering and/or allergic reactions, collapse, symptomatic hypocalcaemia) of the different substitution fluids used during therapeutical plasmapheresis.

DESIGN

Multicentric retrospective comparative study designed to explore the side effects due to the replacements fluids (albumin alone or associated with dextran 40, modified fluid gelatin, hydroxyethyl starch), and to determine the best combination in patients undergoing plasmapheresis.

PATIENTS

46,895 procedures were performed on 5,167 patients between 1990 and 1994. The analysis concerns 33,962 sessions, divided into two groups (group 1: 21,079 sessions from 1990 to 1992 comparing albumin alone versus combined albumin-macromolecules and the different combinations among these, group 2: 12,883 sessions in 1993-1994 comparing albumin alone versus albumin-hydroxyethyl starch). Because of the diversity of the products used, 13,029 sessions were not studied because groups of small sample sizes were formed.

MEASUREMENTS AND RESULTS

In group 1, the comparison of albumin + macromolecules with albumin alone, shows the best haemodynamic tolerance, lower frequency of fever shivering and/or allergic reactions in the albumin alone subgroup. On the other hand, hypocalcaemia is significantly higher in this subgroup. The combinations albumin + dextran 40 (but after hapten inhibition) and albumin + hydroxyethyl starch are equivalent. Albumin + modified fluid gelatin is the combination presenting the highest incidence in terms of allergic manifestations. In group 2, albumin + hydroxyethyl starch versus albumin alone, the former is preferable in terms of the three side effects studied.

CONCLUSION

The results of this study show a combination of albumin 4% hydroxyethyl starch to replace plasma during plasma exchange to be the method presenting the lowest morbidity and the best cost/effectiveness ratio.

Cryofiltration apheresis in the treatment of cryoprecipitate induced diseases

Cryoprecipitates include cryoglobulins, cryofibrinogen, cryoparaproteins, and some cold hemagglutinins. We used 3 different methods: plasma exchange (PE), plasma filter (PF), and cryofilter (CF) to remove cryoproteins. Twenty-four patients received more than 800 CF, PF, and PE treatments. The PF and CF methods have average pore sizes of 0.03 microm and 4.3 microm and surface areas of 2.0 m2 and 0.135 m2, respectively. The plasma was separated by centrifugation, cooled to 4 degrees C, and the cryoprecipitate was removed by CF. Albumin solution 5% was used as a replacement fluid in PE, but no albumin was required when using PF or CF. Our results show that the CF and PF methods do not cause complement activation. Although PE is effective for removal of cryoproteins, it is nonspecific, nonselective, and requires human albumin or fresh frozen plasma. If intensive PE is required, it may cause depletion of immunoglobulins and coagulation factors and other vital plasma components. The PF removes macromolecules such as IgM and IgG effectively and it is semiselective. It removes any protein with a molecular weight > or = 200,000, which makes it semispecific treatment. CF is very effective and selectively removes cryoproteins; therefore it is a specific therapy. In conclusion, cryofiltration apheresis is the best method to remove cryoproteins in the treatment of cryoprecipitate induced diseases.

International forum: France. The national survey of plasma exchange and therapeutic cytapheresis in France

Created in 1985, the French Society of Haemapheresis (SFH) Registry is the largest data base of plasma exchange (PE) in the world. Data analysis shows that neurological diseases are the most frequent indications for PE in France and that improvement in technique has reduced early complications. As for therapeutic cytapheresis, peripheral blood stem collection represents the major activity (64%). The second most common activity is UVA extracorporeal photochemotherapy.

Aprotinin reduces the need for blood products during liver transplantation

BACKGROUND

Bleeding complications and blood product consumption have been a major concern during liver transplantation. Prevention of plasminogen activation and fibrinolysis by aprotinin administration has been shown to reduce perioperative bleeding during operations associated with high blood-product consumption.

PATIENTS AND METHODS

Use of blood-products (packed red cells, frozen plasma, platelets, and cryoprecipitate) was analyzed both during the three stages of orthotopic liver transplantation and during total hospitalization of the 26 patients transplanted without aprotinin and the subsequent 40 patients with aprotinin. A similar analysis was performed for 15 patients immediately before and after the introduction of aprotinin to eliminate the "learning curve" effect for liver transplantation. The effect of epsilon-amino-caproic acid was analyzed as 13 patients received neither epsilon-aminocaproic acid nor aprotinin and 13 patients received epsilon-aminocaproic acid but not aprotinin.

RESULTS

There was a significant reduction in total hospital use of cryoprecipitate, frozen plasma, platelets, and red cells in the aprotinin-treated patients. This reduction was seen during the anhepatic and reperfusion stages of liver transplantation. There was no difference in blood product consumption between the groups who were or were not treated with epsilon-aminocaproic acid.

CONCLUSION

Aprotinin significantly reduces the need for red cell, frozen plasma, platelet, and cryoprecipitate transfusion use during orthotopic liver transplantation, and appears to be more efficacious than epsilon-aminocaproic acid.

1991 registry of the French Society of Hemapheresis (SFH): preliminary results for the first year of the on-line computer access file. The Registry Study Group

From 1985 to 1990, the French Society of Hemapheresis (SFH) managed a National Registry of Plasma Exchange (PE) which included a data collection service, computer data input and statistical analysis of the total operation. The management of this registry did, however, encounter some problems. In 1991, an on-line computer access file was created, permitting French centers to input their data in Minitel Registry System. As a result, analysis on a national scale has proven more time-effective and data collection errors have been noticeably reduced. In January 1991, 43 centers were connected to the Minitel System. Only 17 centers, representing 4706 PEs, entered their data directly to the Minitel System during 1991 and, during the first term of 1992, a further 11 centers, representing 3258 PEs, communicated their data on paper in batch mode. The final total for 1990 was: 26 centers representing 860 patients and 7991 PEs. It is likely that some small imperfections have already developed during processing of the 1991 data, but these will be corrected as they are entered into the system. With the implementation of the Minitel System the French PE Registry represents a more accurate picture of plasmapheresis activity in France.

Status of therapeutic apheresis in Europe

The development and future trend of therapeutic apheresis in Europe was analyzed. Demographic data on its distribution were collected with the help of the marketing departments of four commercial companies. The differences in application in European countries were examined and compared with North America and Japan.

Plasma exchange in Canada. The Canadian Apheresis Study Group

Since 1982 the Canadian Apheresis Study Group (CASG) has collected data on plasma exchange activities in Canada. In 1987, 5907 such procedures were carried out on 700 patients for more than 22 different diseases; this represented an increase of 28% over the figure for 1982. A shift in activity has occurred over the years; originally hematologic disorders accounted for most of the procedures; however, in 1987, 60% of the exchanges were done to treat neurologic disorders, mainly myasthenia gravis and acute and chronic Guillain-Barré syndrome. Several prospective randomized clinical trials have recently been completed by the CASG in the hope of determining the optimal application of plasma exchange. These studies, currently under review, include 168 patients with multiple sclerosis, 100 with thrombotic thrombocytopenic purpura and 43 with rapidly progressive glomerulonephritis. Reactions occur in 12% of cases; they are usually minor and are limited to circumoral paresthesia, mild hypertension or hypotension and hives.