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.     

Iatrogenic thyrotoxicosis and the role of therapeutic plasma exchange

Thyroid storm or severe thyrotoxicosis results from extreme thyroid hormone elevation. Therapy includes medical management to prevent hormone production, release, recycling, and peripheral conversion while stabilizing adrenergic tone. Thyroid dysfunction is the usual cause but it can be due to excessive thyroid hormone ingestion. Therapeutic plasma exchange (TPE) has been used to rapidly remove protein‐bound thyroid hormone. American Society for Apheresis guidelines make a weak recommendation to perform TPE in selected patients in the treatment of thyrotoxicosis based on low quality evidence. We present a case of excessive thyroid replacement hormone ingestion treated by TPE. The patient presented with the clinical picture of thyroid storm, including cardiovascular compromise and massively elevated total and free T3 (525 ng/dL, nl 80–200 ng/dL and 28 pg/mL, nl 2.0–3.5 11 pg/mL), which failed medical therapy. A single, one plasma volume TPE was performed. Both total and free T3 demonstrated substantial declines immediately after TPE with the patient's mental status returning to near‐normal. Thyroid hormone extraction efficiency and collection efficacy were calculated as 37.1% and 40.8%, respectively. Prior to discharge on day 6, the patient's compounding pharmacy indicated that a “bad batch” of bovine thyroid gland derived replacement hormone had been produced. TPE appears to be effective in removing protein bound thyroid hormone in extreme iatrogenic thyrotoxicosis.     

The Italian Registry for Therapeutic Apheresis. A report from the Apheresis Study Group of the Italian Society of Nephrology

Many clinical indications and different technical issues have been reported on therapeutic apheresis: much criticism has also been recorded in several instances, mainly due to the lack of large clinical trials to validate collected data. A Registry where all the available data can be organized and analyzed therefore becomes a priority for all the professionals involved in apheresis. The purpose of this report is to describe the data submitted from 1994 to 2004 from 15,285 treatments on 1,477 patients from 44 Centers, including mainly, but not exclusively, Nephrological Units, collected by the Apheresis Study Group of the Italian Society of Nephrology in 15 Italian regions. Plasma exchange accounted for 56.2% of the procedures, and of these 50.4% were performed by filtration. Plasma treatment was used in 40.1% of procedures, namely with Protein A immunoadsorption (14.6%), LDL-Cholesterol dextran sulfate adsorption (9.7%), and semiselective cascade or double filtration (12.6%). Cell apheresis, limited to photopheresis, was used in 0.85% of cases, and whole blood treatment (direct adsorption lipoprotein, and molecular adsorption recirculating system) in 2.7%. The procedures analyzed here account for less than 20% of estimated therapeutic apheresis performed in Italy, according to the national survey of activity performed for year 2000 by the Italian Apheresis Society. Notwithstanding that the data are largely incomplete, they are sufficiently informative for a definite trend: plasma treatment with filtration on fractionation filters and adsorption must be used as often as possible, instead of plasma exchange, thus obtaining the most selective removals.     

Clinical evaluation of a flat-plate membrane plasma exchange system

A new flat-plate membrane plasma separation system specifically designed for therapeutic plasma exchange (TPE) was clinically evaluated in both research and routine clinical settings. The study included a comparison to a currently available centrifugal cell separation system employed for TPE. A total of 267 membrane procedures were performed on 39 patients over a 14-month period. Both qualitative and quantitative studies showed that membrane plasma exchange procedures were equivalent to centrifugal procedures in the removal of plasma constituents from patients. A notable difference between the two types of procedure was the effect on the peripheral blood platelet count: the plasma filtrate from the membrane system was essentially cell-free and platelet counts fell only 11% during the procedure, compared to a 53% decrease during the centrifugation runs. Patient responses to both types of procedure were similar and the frequency of side-effects was low. A sampling of patient opinion revealed a preference for the membrane system for a variety of reasons. Procedure times were shorter with the membrane system because of higher achievable blood flow rates, and thus higher plasma exchange rates, while the overall nursing time requirement was lower. The results show that this flat-plate membrane TPE system enables rapid and effective plasma exchange therapy, and offered a number of monitoring and control functions that provided a safer, more efficient therapeutic procedure in the majority of patient treatments performed in this study.     

Therapeutic plasma exchange and pregnancy: A case report and guidelines for performing plasma exchange in a pregnant patient

Therapeutic plasma exchange (TPE) has been demonstrated to be of significant clinical value in a number of diseases and conditions, with well‐established guidelines and recommendations. However, technical support in providing this procedure for pregnant patients is largely absent from these recommendations, leaving therapeutic apheresis practitioners without guidance to safely and adequately treat appropriate conditions in this important patient population. Here, we describe our experience in treating a 35‐year‐old pregnant patient with relapsing‐remitting multiple sclerosis with TPE. Additionally, we outline the principle considerations when developing her treatment plan, and we provide recommendations for apheresis practitioners when performing TPE in pregnant patients. J. Clin. Apheresis 32:191–195, 2017. © 2016 Wiley Periodicals, Inc.     

Cyclosporin-induced hypertriglyceridemia with prompt response to plasma exchange therapy

A case of severe cyclosporin-induced hypertriglyceridemia that prompted plasma exchange therapy is reported. Hyperlipemic retinitis, headache, stupor, and peripheral paresthesias became apparent when the level of triglycerides exceeded the 1,500 mg/dL level. Two plasma exchanges were required to halt disease progression. This is the second time that plasma exchange was used in a bone marrow transplanted patient on cyclosporin-A therapy. In both cases hypertriglyceridemia became apparent and symptomatic after approximately 7 months of therapy with cyclosporin.     

Therapeutic apheresis in neurological disorders: a survey of the evidence in support of current category I and II indications for therapeutic plasma exchange

Neurologic disorders constitute the largest group of indications for therapeutic plasma exchange. Although some of the traditional indications are supported by properly designed randomized trials, others are not. This article provides a critical look at the evidence in support of the assignment by ASFA of Category I or II indications to neurologic disorders in its most recent (2007) evaluation of therapeutic apheresis.     

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.     

Complications of therapeutic plasma exchange: a prospective study of 1,727 procedures

The type and number of complications was prospectively examined in 1,727 successive TPE treatments in 174 patients over 66 months at a single center. Most treatments were prescribed for thrombotic thrombocytopenic purpura (TTP; 42%), recurrent focal segmental glomerulosclerosis (FSGS; 22%), or myasthenia gravis (MG; 13%). About 57% of treatments used albumin-saline as the replacement solution and 43% used fresh-frozen plasma (FFP), almost all for TTP. There were 889 complications; 614 treatments (36% of the total) involved a complication. Most complications were minor; there were no deaths. Three treatments (0.2%) were discontinued due to a complication, and 2 (0.1%) required transfer to a higher acuity hospital bed. The most common complications were fever (7.7% of treatments), urticaria (7.4%), and hypocalcemic symptoms (7.3%). 42% of treatments with FFP involved a complication, compared to 30% of treatments using albumin-saline (P < 0.0001). The most common complications with FFP were urticaria (17%) and pruritis (13%); these occurred more commonly than in patients receiving albumin-saline. The most common complications with albumin-saline replacement were hypocalcemic symptoms (8.2%) and mild hypotension (8.1%). Mild and severe hypotension was significantly (P < 0.0001) more common with albumin-saline replacement. TPE is associated with a number of minor complications. Complications occur more commonly with FFP replacement compared to albumin-saline replacement. Pruritis and urticaria occur more commonly with FFP, and hypotension occurs more commonly with albumin-saline.     

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.