The Monitoring of Serum Fibrinogen in Patients with End Stage Renal Disease Undergoing Plasma Exchange for High Risk Kidney Transplantation

Abstract

Background: Plasma exchange is being increasingly used in the antibody reduction for high risk kidney transplantation. There were some reports of post-transplant bleeding in patients who had a large number of plasma exchange. In addition, wide variation in technique is reported, thereby adding to the confusion that exists about both efficacy and safety. Since changes in coagulation factors are known to occur to following plasmapheresis, we studied serial changes of serum fibrinogen in patients undergoing plasma exchange for antibody reduction before high risk kidney transplantation. Methods: Eighty eight times of plasma exchange were carried out at every other day in 18 patients before kidney transplantation, using the COBE® Spectra™ apheresis system. Sixteen patients were received ABO incompatible living donor kidney transplantation and 2 patients were received cross matching positive living donor kidney transplantation in our hospital from 2009 to 2011. The levels of serum fibrinogen were measured at pre-exchange, post-exchange one day and two days. In procedure, 1.0 time the calculated plasma volume was replaced with an electrolyte solution containing 5% salt-free human albumin or fresh frozen plasma (FFP). Anticoagulation was achieved using a whole venous blood to acid-citrate dextrose ratio of 15 to 1. Median flow rates, plasma collection, and procedure times were respectively 80 ml/minute, 20 ml/ minute, 80 minutes in cases of 5% albumin solution replacement and 40 ml/minute, 20 ml/minute, 150 minutes in cases of FFP replacement. Results: The cases with 5% albumin solution replacement were 55, and with FFP were 28. In cases of 5% albumin solution replacement, the mean serum fibrinogen level was 230.35 mg/dL, 138.93 mg/dL and 167.07 mg/dL at pre-exchage, post-exchage 1 day and post exchage 2 days. And in case of FFP replacement, the mean serum fibrinogen level was 168.68 mg/dL, 178.25 mg/dL and 181.18 mg/dL at the same time as before. The serum fibrinogen levels were markedly reduced immediately following the procedure and did not have returned to prior levels within 48 hours in cases of 5% albumin solution replacement. But the serum fibrinogen levels were increased in cases of FFP replacement.Table: [The serum fibrinogen levels in subjects(mg/dL).]Conclusion: In spite of every other day schedule, consecutive plasma exchange with 5% albumin solution replacement has a decrease of serum fibrinogen in patients with end stage renal disease before high risk kidney transplantation. And it may be associated with decrease coagulation and post-transplant bleeding. It is useful to prevent post-transplant bleeding that the use of FFP as replacement fluid or the use of cryoprecipitate containing fibrinogen and other coagulation factors.