A single center retrospective study: Comparison between centrifugal separation plasma exchange with ACD-A and membrane separation plasma exchange with heparin on acute liver failure and acute on chronic liver failure

The purpose of this retrospective study is to compare the efficacy and safety of the centrifugal separation therapeutic plasma exchange (TPE) using citrate anticoagulant (cTPEc) with membrane separation TPE using heparin anticoagulant (mTPEh) in liver failure patients. The patients treated by cTPEc were defined as cTPEc group and those treated by mTPEh were defined as mTPEh group, respectively. Clinical characteristics were compared between the two groups. Survival analyses of two groups and subgroups classified by the model for end-stage liver disease (MELD) score were performed by Kaplan–Meier method and were compared by the log-rank test. In this study, there were 51 patients in cTPEc group and 18 patients in mTPEh group, respectively. The overall 28-day survival rate was 76% (39/51) in cTPEc group and 61% (11/18) in mTPEh group (P > .05). The 90-day survival rate was 69% (35/51) in cTPEc group and 50% (9/18) in mTPEh group (P > .05). MELD score = 30 was the best cut-off value to predict the prognosis of patients with liver failure treated with TPE, in mTPEh group as well as cTPEc group. The median of total calcium/ionized calcium ratio (2.84, range from 2.20 to 3.71) after cTPEc was significantly higher than the ratio (1.97, range from 1.73 to 3.19) before cTPEc (P < .001). However, there was no significant difference between the mean concentrations of total calcium before cTPEc and at 48 h after cTPEc. Our study concludes that there was no statistically significant difference in survival rate and complications between cTPEc and mTPEh groups. The liver failure patients tolerated cTPEc treatment via peripheral vascular access with the prognosis similar to mTPEh. The prognosis in patients with MELD score < 30 was better than in patients with MELD score ≥ 30 in both groups. In this study, the patients with acute liver failure (ALF) and acute on chronic liver failure (ACLF) treated with cTPEc tolerated the TPE frequency of every other day without significant clinical adverse event of hypocalcemia with similar outcomes to the mTPEh treatment. For liver failure patients treated with cTPEc, close clinical observation and monitoring ionized calcium are necessary to ensure the patients' safety.     

Membrane‐based therapeutic plasma exchange (mTPE): Technical and clinical experience

Therapeutic plasma exchange (TPE) has long been utilized to manage a variety of immune‐mediated diseases. The basic principle relies on removal of circulating pathogenic substances from the bloodstream. Methods of plasma separation include centrifuge (cTPE) and membrane (mTPE). Although mTPE has existed for a few decades, recent advances in developing highly permeable filters that are compatible with currently existing dialysis machines has opened a new frontier. Published data in the area of technical and clinical experience with mTPE is lacking. We report our single center experience of 998 inpatient mTPE treatments performed in 237 patients at a large tertiary care academic center. The most common treatment indication was neurologic. We found a very low incidence of patient‐reported complications. Filter clotting without the use of anticoagulation occurred in 7.7% of treatments. Laboratory parameters that significantly changed during the course of therapy included serum potassium, platelet count, and partial thromboplastin time. We found that mTPE can be safely and efficiently performed as an alternative to cTPE, and suggest an individualized approach when prescribing this therapy.     

Preoperative therapeutic plasma exchange in patients with thyrotoxicosis

The purpose of this report was to determine the effectiveness of therapeutic plasma exchange (TPE) in preoperative preparation of patients with thyrotoxicosis scheduled for either thyroid or nonthyroid surgery. We retrospectively reviewed 11 patients with thyrotoxicosis and those who prepared surgery with plasmapheresis between 1999 and 2008 at our institution. Ten patients underwent thyroid surgery and one patient was operated for femur fracture during antithyroid drug treatment. The indications for plasmapheresis in all patients with severe thyrotoxicosis were poor response to medical treatment (seven patients), agronulocytosis due to antithyroid drugs (three patients), iodine‐induced thyrotoxicosis (Jodd Basedow effect in one patient), and rapid preparation for urgent orthopedic operation (one patient). After TPE, we observed a marked decrease in free thyroxin (FT3) and free triiodothyronin (FT4) levels; however, the decline in the biochemical values were not statically significant (P > 0.62, P > 0.15). Although both FT3 and FT4 levels remained above the normal limits in two of 11 patients, the signs and symptoms of thyrotoxicosis improved in all patients and no thyroid storm observed during the perioperative period. TPE can be considered a safe and effective alternative to prepare patients with thyrotoxicosis for surgery when drug treatment fails or is contraindicated and when emergency surgery is required. J. Clin. Apheresis, 2009. © 2009 Wiley‐Liss, Inc.     

Acquired factor XI deficiency and therapeutic plasma exchange

Congenital factor XI (FXI) deficiency is associated with a variable bleeding phenotype. Recent reports have documented the use of therapeutic plasma exchange to rapidly and isovolumetrically increase FXI levels before invasive procedures in patients with congenital FXI deficiency. We report a case of acquired FXI deficiency in a pregnant woman with lupus. We proved that the inhibitor was an IgG, therefore potentially capable of crossing the placenta. While immune suppression eliminated detectable circulating inhibitor, the woman's FXI remained quite low. A multi‐disciplinary team was formed and therapeutic plasma exchange with 100% plasma replacement was performed when the patient went into labor, to acutely raise her FXI level and remove any potential non‐neutralizing inhibitor. The mother had a controllable level of bleeding during post‐TPE cesarean section; the baby had no bleeding and the baby's FXI levels were not overtly abnormal. Therapeutic plasma exchange in acquired FXI deficiency (or other acquired hemophilias) can both acutely isovolumetrically raise factor levels and remove any circulating inhibitor.     

Recurring extracorporeal circuit clotting during continuous renal replacement therapy resolved after single-session therapeutic plasma exchange

We report a case of a 17-year-old white male with multiple fractures and multiorgan failure who developed oliguric acute renal failure requiring continuous renal replacement therapy. Repeated clotting of the extracorporeal circuit (ECC) prevented delivery of a minimally acceptable dose of renal replacement therapy despite adequate anticoagulation and dialysis catheter exchanges. Evaluation for a primary hypercoagulable state was negative, but his fibrinogen was elevated (1,320 mg/dL, normal range: 150-400 mg/dL), which is likely induced by his severe inflammatory state. A single session of therapeutic plasma exchange (TPE) with albumin and normal saline replacement was performed with subsequent drop in fibrinogen to 615 mg/dL. No further episodes of premature ECC clotting occurred, suggesting plasma factor(s) removed may have contributed to the clinical hypercoagulable state. TPE may play an adjunctive role in select cases of recurrent ECC clotting refractory to current anticoagulation techniques.     

Therapeutic plasma exchange as a therapeutic modality for the treatment of IVIG complications

Intravenous immunoglobulin (IVIG) is used for the treatment of a number of inflammatory conditions. Hemolysis due to passive transfer of blood group antibodies is a well recognized complication of IVIG therapy. Therapy is largely supportive and consists of blood product support and hemodialysis. We report the use of therapeutic plasma exchange (TPE) as adjunct therapy for three patients with complications attributed to IVIG. Two patients had hemolysis attributed to IVIG; one patient was blood group A and the other blood group O. The third patient was an orthotopic heart transplant recipient with a type A donor heart, and anti‐A antibodies detected after infusion of IVIG for suspected antibody mediated rejection. Two patients had anti‐A titers available that decreased after initiation of plasma exchange. The blood group O patient with hemolysis had a gradual stabilization of hemoglobin and resolution of the positive DAT. TPE may be useful therapy for patients with severe hemolysis caused by IVIG or at risk for tissue damage by blood group antibodies. J. Clin. Apheresis 30:371–374, 2015. © 2015 Wiley Periodicals, Inc.     

治疗性血浆置换术295例及其血浆使用情况分析

目的 分析治疗性血浆置换术(TPE)的临床应用效果和血浆使用情况.方法 对本院6年间的295例行TPE患者的治疗效果与血浆使用情况作回顾性分析.结果 1)基本情况:295名患者共作TPE 688次,(1～19)次/人,平均(2.26±2.13)次/人,治疗人数逐年增加,治疗数最多的病种为肝脏疾病,占总数的80.3％(237/295),其他包括肾脏疾病22例(7.5％)、药物和食物中毒14例(4.7％)、热射病4例(1％)、自身免疫性疾病12例(4.1％)、血栓性血小板减少性紫癜4例(1.0％)、HELLP综合征1例、格林-巴利综合征1例.2)置换液:以血浆(经滤白及病毒灭活处理)为主,297例688次TPE共用血浆1 523 380 mL,平均每次用量(2 184.62±395.59) mL.3)治疗情况:总体治疗有效率能2007年的30％上升至2012年65.9％;TPE不良反应率3.0％(21/688),主要为心血管反应4例、低钙血症5例、过敏11例.结论 随着TPE适应证和治疗范围的扩大,临床合理使用血浆能从量和质上保障TPE技术的展开,对于确保TPE安全、有效显得更为重要.     

Partial plasma protein replacement in therapeutic plasma exchange

We wished to determine whether subtotal replacement of protein in plasma removed at plasma exchange would be adequate to prevent hypovolemia and hypoproteinemia. Seven well nourished outpatients with chronic progressive multiple sclerosis underwent 60 plasma exchanges in which two liters of plasma were replaced with 750 ml saline followed by 1250 ml of a 5% albumin solution (62.5% albumin replacement). Total serum protein, protein electrophoresis, and immunoglobulin levels were measured before and after each exchange. Clinically, the exchanges were well tolerated. Total serum protein dropped by a mean of only 18% during the study and mean preexchange serum albumin levels were unchanged, even though immunoglobulins decreased by 57–72%. We conclude that in well nourished patients, partial albumin replacement of this magnitude is an adequate substitute for plasma removed in a plasma exchange.     

ABO‐incompatible living donor kidney transplantation without post‐transplant therapeutic plasma exchange

Blood group incompatibility remains a significant barrier to kidney transplantation. Approximately, one‐third of donors are blood group incompatible with their intended recipient. Options for these donor‐recipient pairs include blood group incompatible transplantation or kidney paired donation. However, the optimal protocol for blood group incompatible transplantation is unknown. Protocols differ in techniques to remove ABO antibodies, titer targets, and immunosuppression regimens. In addition, the mechanisms of graft accommodation to blood group antigens remain poorly understood. We describe a blood group incompatible protocol using pretransplant therapeutic plasma exchange (TPE), high‐dose intravenous immunoglobulin, and rituximab in addition to prednisone, mycophenolate mofetil, and tacrolimus. In this protocol, we do not exclude patients based on a high initial titer and do not implement post‐transplant TPE. All 16 patients who underwent this protocol received a living donor transplant with 100% patient and graft survival, and no reported episodes of antibody‐mediated rejection to date with a median follow‐up of 2.6 years (range 0.75–4.7 years). We conclude that blood group incompatible transplantation can be achieved without post‐transplant TPE. J. Clin. Apheresis 30:340–346, 2015. © 2015 Wiley Periodicals, Inc.     

Drug-resistant bronchial asthma successfully treated with plasma exchange

Two patients suffering from allergic bronchial asthma who showed no improvement despite six and four weeks, respectively, of drug therapy were successfully treated with therapeutic plasma exchange. The first patient had no attacks over a period of five months, and the other patient had none for over one year. Although this report only deals with single observations, we believe that therapeutic plasma exchange is of particular value for patients with severe allergic bronchial asthma because it eliminates in addition to immunocomplexes other substances, including antigens, rapidly from the blood. This means that it is possible to directly intervene in the pathomechanism. However, further investigations are necessary in order to corroborate this successful therapy.     

低分子肝素对急性胰腺炎患者预后的改善作用

目的 观察低分子肝素抗凝治疗对急性胰腺炎患者预后的影响。方法 将41例急性胰腺炎患者随机分为抗凝治疗组(17例)和常规治疗对照组(24例)。抗凝治疗组给予低分子肝素钠40 mg或低分子肝素钙0.01 ml／kg皮下注射,12 h 1次;其他治疗同常规治疗对照组。观察两组患者的血清酶学及预后。结果低分子肝素抗凝治疗能明显改善急性胰腺炎患者的血象及动脉血氧分压变化,缩短住院时间,并能在一定程度上降低急性水肿型胰腺炎的重症化率,减少其二次手术率,降低病死率。低分子肝素抗凝治疗并没有加重急性胰腺炎的出血倾向或出血并发症。结论 低分子肝素抗凝治疗对急性胰腺炎是安全、有效的,能明显改善急性胰腺炎患者的预后。     

Factor V and VIII deficiency treated with therapeutic plasma exchange prior to redo mitral valve replacement

A 33‐year‐old male was admitted to the hospital for a repeat mitral valve replacement. The original surgery, performed in India in 2008 due to rheumatic heart disease, required massive amounts of plasma replacement during and after the surgery. The patient was admitted to our hospital with extremely low Factor V and Factor VIII activities due to a rare combined Factor V and Factor VIII deficiency. His clinical condition on admission was grave due to severe pulmonary hypertension. It was decided to replace the patient's Factor V using therapeutic plasma exchange (TPE) with fresh frozen plasma (FFP) just prior to surgery, and his Factor VIII with Factor VIII concentrate. The patient tolerated the valve replacement surgery very well, without excessive bleeding, and received several more TPE procedures postoperatively. He was successfully made replete with both coagulation factors with little to no bleeding during the procedure and postoperatively. TPE is a promising modality for the treatment of patients with similar factor deficiencies for which a specific factor concentrate is not available, especially those at risk of fluid overload from plasma transfusion. J. Clin. Apheresis 32:196–199, 2017. © 2016 Wiley Periodicals, Inc.