Abstract
BackgroundTherapeutic plasma exchange (TPE)-based protocols immediately before cadaveric donor kidney transplantation have been extensively used in highly sensitized recipients. Plasma is generally preferred over human albumin as replacement fluid to avoid depletion of coagulation factors and perioperative bleeding. The aim of this study was to estimate bleeding risk after TPE replaced with albumin using rotational thromboelastography (ROTEM).MethodologyTen patients without overt coagulation abnormalities underwent TPE. Standard laboratory coagulation tests (thromboplastin time, activated partial thromboplastin time (aPTT), international normalized ratio (INR), thrombin clotting time, fibrinogen levels and antithrombin activity) were compared with thrombelastometry analysis (EXTEM and INTEM tests) before and after TPE.Principal FindingsTPE significantly reduced fibrinogen levels (482 ± 182 vs. 223 ± 122 mg/dL), antithrombin activity (103 ± 11 vs. 54 ± 11 %), and prolonged aPTT (28 ± 3 vs. 45 ± 8 s), thromboplastin time (108 ± 11 vs. 68 ± 11 %), INR (0.95 ± 0.06 vs. 1.25 ± 0.16), and thrombin clotting time (18 ± 2 vs. 20 ± 3 s). INTEM and EXTEM analyses revealed significantly prolonged clot-formation time and reduced maximum clot firmness.Conclusions/SignificanceTPE replaced with albumin induces significant changes in global hemostasis parameters thus potentially increasing bleeding risk. Therefore, pretransplant TPE should be considered carefully in indicated patients before kidney transplantation. The role of the ROTEM point-of-care test to estimate the risk of bleeding in renal transplantation needs to be evaluated in further studies.
Highlights
Therapeutic plasma exchange (TPE) is used as a rescue therapy for antibody-mediated diseases but causes far more effects than simple antibody depletion [1, 2]
In the USA and Japan, TPE is a standard procedure in desensitization of patients before ABO incompatible (ABOi) renal transplantation (RTx) [3, 4]
After TPE, significant decreased values were obtained in erythrocytes (-2%), hemoglobin (-5%), hematocrit (-6%) and platelets (-11%) while white blood count showed an increase (+6%, not significant)
Summary
Therapeutic plasma exchange (TPE) is used as a rescue therapy for antibody-mediated diseases but causes far more effects than simple antibody depletion [1, 2]. In the USA and Japan, TPE is a standard procedure in desensitization of patients before ABO incompatible (ABOi) renal transplantation (RTx) [3, 4]. It is employed for depletion of antibodies in high-risk sensitized patients immediately before RTx [5]. Because plasma replaces all plasma proteins it is potentially the solution of choice in the perioperative management of the kidney transplant recipient to avoid removal of clotting factors and subsequent increased bleeding risk [10]. Plasma is generally preferred over human albumin as replacement fluid to avoid depletion of coagulation factors and perioperative bleeding. The aim of this study was to estimate bleeding risk after TPE replaced with albumin using rotational thromboelastography (ROTEM)
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