Effect Of Therapeutic Plasma Exchange Research Articles

The mechanisms of action of plasma exchange

The initial description of therapeutic plasma exchange (TPE) in an animal model was published almost 100years ago. Since that time, this treatment has been applied to a wide variety of diseases but limited research has been published examining the mechanisms of action of TPE. The therapeutic effects of TPE could include the removal of pathological substances from the blood, such as monoclonal paraproteins and autoantibodies, as well as the replacement of deficient plasma components when plasma is used as a replacement fluid. Beyond these potential mechanisms, other possible mechanisms include possible alterations in lymphocyte proliferation and function that could sensitize these cells to immunosuppressant and chemotherapeutic agents and alterations in the immune system including changes in B and T cell numbers and activation, increased T suppressor function, and alteration in T-helper cell type 1/2 (Th1/Th2) ratio. Much remains unknown about the mechanisms of action of TPE, indicating a need for basic research into this therapy.

Effect of therapeutic plasma exchange on coagulation parameters in patients on warfarin

Therapeutic plasma exchange (TPE) without plasma replacement results in coagulation factor removal. Warfarin decreases the activity of vitamin K dependent coagulation factors. The combined effect of TPE and warfarin on the coagulation system has not been studied. A prospective, observational study was conducted in patients undergoing TPE while on warfarin. One plasma volume TPEs were performed on the COBE Spectra Apheresis System (Terumo BCT, Lakewood, CO) with 5% albumin. International normalized ratio (INR), fibrinogen, and factor II activity were obtained pre and post procedure. Eight patients underwent 121 TPEs that met study criteria with pre and post data. The average pre values were INR 2.09 ± 0.58, fibrinogen 263 ± 76 mg/dl, and factor II 29 ± 16% and the average post values were INR 4.12 ± 1.44, fibrinogen 105 ± 31 mg/dl, and factor II 13 ± 7%. The pre-INR was ≥2.00 for 55% of TPEs. The pre value (Y0 ) predicts the post value (Y) by the following equations Y = -0.54 + 2.21Y0 , Y =12.10 + 0.35Y0, and Y =1.83 + 0.39Y0 for INR, fibrinogen, and factor II respectively. In conclusion, pre procedure laboratory values can predict the post laboratory values for patients on warfarin receiving single plasma volume TPE with albumin replacement. The post-INR is approximately twice the pre-INR. At normal and mildly elevated pre-INR, the effect of TPE on the INR is less marked. A single plasma volume TPE decreases the plasma level by ∼65% for fibrinogen and 60% for factor II.

Effectiveness of therapeutic plasma exchange in patients with intermediate syndrome due to organophosphate intoxication

ObjectiveWe aimed to determine effectiveness of therapeutic plasma exchange (TPE) in patients with intermediate syndrome (IMS) due to organophosphate (OP) intoxication. MethodsPatients diagnosed with IMS due to OP intoxication were included in this prospective study. Therapeutic plasma exchange procedure was performed with fresh frozen plasma as a replacement fluid via Fresenius-AS-TEC 204 device by Therapeutic Apheresis Unit to patients who developed IMS during follow-up. Samples were taken from patient's blood and waste plasma collected in the device before and after TPE procedure to be studied in laboratory for detection of organic phosphate and pseudocholinesterase (PChE) levels. In this study, SPSS 18.0 software package was used for statistical analysis of the data obtained. Level of statistical significance was taken as P < .05 for all tests. ResultsOf all 17 patients, 4 (23.5%) were female, and 13 (76.5%) were male. A statistically significant decrease was detected in organic phosphate levels in the plasma of patients after TPE procedure (P = .012). A statistically significant increase was detected in PChE levels in the plasma of patients after TPE procedure (P = .014). Of 17 patients included in the study, 13 patients showed clinical improvement and were discharged after the TPE process. ConclusionIn our study, it was observed that a significant decrease in the level of blood plasma OP and a significant increase in the level of PChE were achieved with TPE process in the early period of IMS due to OP poisoning. This study indicates that TPE is one of the effective treatment options for IMS due to OP intoxication.

Role of therapeutic plasma exchange in the complex treatment of severe kidney diseases

PURPOSE: The strongest effect of therapeutic plasma exchange (TPE) is achieved in diseases with immune and autoimmune genesis, hyperviscous conditions and intoxications of various origins. The aims of the study were to assess the long-term effect of TPE in the complex therapy of severe renal diseases and to highlight therapeutic strategies necessary to achieve good clinical results. MATERIAL AND METHODS: During the period 1980-2010, TPE was carried out in the form of a complex treatment of 87 patients with immune nephropathies and 44 patients with malignant myeloma. The primary diseases were the following: chronic glomerulonephritis - 42, lupus nephropathy - 31, Henoch-Schonlein nephritis - 8, Wegener granulomatosis ± four and Goodpasture syndrome - two patients. The diagnosis was confirmed after a puncture kidney biopsy in 72 (82.8%) patients with immune nephropathies. TPE was performed using centrifugal or filtration methods. RESULTS: The patients with immune nephropathies underwent between 5 and 7 consecutive plasma exchanges daily or every two days. A three consecutive days of corticosteroid pulse therapy was initiated after last procedure followed by conventional immunosuppressive therapy. After serial TPE a significant decrease in anti-GMB antibodies and circulating immune complexes was detected. Continuous clinical and paraclinical remission was achieved in 62.7% of the patients who received the combined treatment. CONCLUSION: TPE has a beneficial effect after being included in the complex treatment of patients with severe immune nephropathies. The immunomodulation contributes to the successful management of severe ongoing autoimmune processes. In patients with hyperviscosity, “supporting” TPE every 2 or 3 months is required to lower the increased viscosity, to prevent thromboembolic complications, and to slow-down nephropathy progression. Scripta Scientifica Medica 2013; 45(1): 66-70.

Therapeutic effect of plasma exchange combined with bilirubin absorption for hyperbilirubinemia: An analysis of 42 cases

Therapeutic effect of plasma exchange combined with bilirubin absorption for hyperbilirubinemia: An analysis of 42 cases

Therapeutic effect of plasma exchange in treatment of hyperlipidemic acute pancreatitis in elderly patients: An analysis of 74 cases

Therapeutic effect of plasma exchange in treatment of hyperlipidemic acute pancreatitis in elderly patients: An analysis of 74 cases

Can plasma exchange therapy induce regulatory T lymphocytes in multiple sclerosis patients?

Plasma exchange is used increasingly as an individual therapeutic decision for treating of severe, steroid-resistant relapses of multiple sclerosis (MS). However, given that its mechanism of action in this CD4(+) T cell-mediated autoimmune disease remains unknown, it is not yet considered as a routine therapy for this prevalent neuroimmune disorder. In this regard, we hypothesized that plasma exchange, by depleting the body of inflammatory mediators that acts as providers of co-stimulatory signals for the adaptive immune system, provides the immune system with an exceptional break for de-novo recognition of autoantigens in a tolerogenic manner. This may lead to an increase in the frequency and function of myelin-specific regulatory T cells. For evaluating this we suggest some in vitro and in vivo studies to analyse the effects of varied dilutions of normal and MS plasmas on the induction of regulatory T cells or on the function of isolated and purified regulatory T cells. Clarifying the effects of therapeutic plasma exchange on regulatory T cells as the major controllers of autoimmune responses may provide us with strong evidence to use this procedure as a disease-modifying treatment in remission phase for reducing the rate and severity of future attacks, in addition to more trustworthy therapy in severe relapses of MS.

Successful therapeutic plasma exchange in a 3.2-kg body weight neonate with atypical hemolytic uremic syndrome

Atypical hemolytic uremic syndrome (aHUS) is a rare form of complement dysregulation disease, and recently various reports have shown that it is associated with one or more mutations in the complement regulatory genes including complement factor H (CFH). Plasma exchange is a therapeutic option for adult patients, but not for a very young infant because of a potential side effect of therapeutic plasma exchange (TPE) itself. Herein, we describe a case of successful treatment of early onset aHUS associated with a novel CFH mutation with total 21 sessions of TPE over a period of 46 days in 3.2 kg 23-day-old neonate.

Stiff-Person Syndrome Following Tick-Borne Meningoencephalitis

Stiff-person syndrome (SPS) is a rare disorder characterized by muscle stiffness and painful spasms. Misdiagnosis may occur due to the fact that the clinical picture of SPS is often atypical. The main pathophysiologic mechanism underlying the development of SPS is insufficient inhibition at the cortical and spinal levels. There is good evidence for a primary autoimmune etiology. A 61-year-old man was admitted to a neurological department due to muscle hypertonia with episodic attacks of painful spasms predominantly affecting axial muscles. The symptoms developed shortly after tickborne meningoencephalitis. Electromyography (EMG) revealed signs of continuous motor unit activity. Antibodies against glutamate decarboxylase (anti-GAD) were highly elevated. We present a case of a man who developed clinically severe anti-GAD positive SPS, provoked by tick-borne encephalitis. After therapeutic plasma exchange (TPE) a rapid, temporary improvement of the clinical and neurophysiological findings was noted. Only after being placed on long-term immunosuppression did the patient achieve stable recovery. This case supports the importance of EMG findings and demonstrates the effect of TPE as well as the need for chronic immunosuppression in severe cases of SPS.

Clinical application of therapeutic plasma exchange in the Three Gorges Area

ObjectiveTo analyze the clinical effect of therapeutic plasma exchange (TPE) on 43 patients in the Three Gorges Area. MethodsPlasma was collected by machine and combined with low-molecular-weight dextran and albumin for use as a replacement fluid for TPE treatment of 43 patients suffering from various blood disorders, diseases of the nervous system, ABO incompatible allogeneic hematopoietic stem cell transplantation and kidney disease. ResultsThe volume of a single TPE was 1.6–2.0l, performed on average 2.3 times/case, and effective in 88.4% (38/43) of cases. ConclusionTPE through the plasma collection machine is a well tolerated, economic and effective treatment.

Therapeutic plasma exchange in children with acute liver failure: assessment of laboratory parameters

The aim of this study is to analyze the effect of therapeutic plasma exchange (TPE) on biochemical and coagulation parameters.

Impact of plasma exchange combined with continuous hemodiaflltration on short-term prognosis and biochemical indicator of patients with severe hepatitis

Objective To explore the short-term therapeutic effect of plasma exchange combined with continuous hemodiafiltration on patients with severe hepatitis. Methods 181 in patients in our department dur-ing Jan. 2002 to Dec. 2006 with chronic severe hepatitis caused by hepatitis B were randomly divided into two groups: Patients of group A (n=87) were treated with internal medicine supporting treatment combined with PE and CHDF,while patients of group B(n=94) were treated with internal medicine supporting treatment com-bined with PE. The short-term therapeutic effect and survival rate were compare and the clinical symptoms and the laboratory examination were determined before and after the treatment. Results There were significant difference between the two groups in short-term efficacy rate,improvement rate of consciousness and serum elee-trolure(P 0.05). Conclusion Internal medicine supporting treatment combined with PE and. CHDF can increase the recent survival rate and improve the consciousness of hepatic en-eephalopathy, and it also effectively redress electrolyte disturbance in serum and keep homeostatic equilibrium of patients; furthermore,this treatment is also convenience and safe, so it can be taken as the major method in treatment of severe hepatitis. Key words: Plasma exchange; Continuous hemodiafiltration; Severe hepatitis; Prognosis

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.

Adjuvant Therapeutic Plasma Exchange in Liver Failure

Therapeutic plasma exchange (TPE) seems to be an effective approach for clearing toxins, immune-mediated antigens, and other particles from the circulation. The aim of this study was to analyze the positive effects of TPE on clinical and biochemical parameters of liver failure. Between January 2001 and March 31, 2005 individuals (men/women, 17/14; median age, 42.7+/-15.8 y) with acute and chronic liver failure who underwent a total of 113 TPEs (median session 3.7) were retrospectively reviewed. TPE was performed using the Fresenius AS-TEC 204 cell separator (Fresenius AG, Germany). The indication for TPE was severe coagulopathy (prothrombin time >20 s), severe hepatic encephalopathy, hyperbilirubinemia, and candidacy for liver transplantation. All patients were examined before and immediately after the last TPE session. When compared with baseline, there was significant improvement in hepatic encephalopathy stage (from median score 3.0 to 1.0, P=0.001), serum prothrombin time (from median 26.0 to 20.0 s, P=0.003), aminotransferases (P<0.001), and total bilirubin levels (from median 35.0 to 23.3 mg/dL, P<0.001) after TPE. Thirteen of the thirty-one individuals (41.9%) died in the hospital. The mean follow-up period of 18 survival patients was 35.9+/-5.6 months and 10 of those survived (55.6%, 10/18). No serious adverse effect of TPE was observed in any of the patients during or after completion of TPE. Only 6 patients experienced minor transfusion reactions. TPE seems to be effective in improving hepatic encephalopathy stage and liver tests in individuals with acute and chronic liver failure. The data suggest that TPE is safe and tolerable in such individuals, however, overall survival remains poor despite TPE.

Use of therapeutic plasma exchange in the management of acute hemorrhagic leukoencephalitis: a case report and review of the literature

Acute hemorrhagic leukoencephalitis (AHLE) is a rare, fatal, central nervous demyelinating disease characterized by a rapid fulminant clinical course. Successful management requires early diagnosis, aggressive management of cerebral edema, and immunosuppression. Therapeutic plasma exchange (TPE) is infrequently used and commences after initial management fails. A 31-year-old man presented with right arm weakness, whose symptoms rapidly progressed to hemiplegia and aphasia. The patient was initially managed with glucocorticosteroids. Decompressive craniotomy and brain biopsies were performed when his intracranial pressure increased. Brain biopsy findings were consistent with AHLE. Mycoplasma pneumonia immunoglobulin G and immunoglobulin M serologies revealed recent infection. Despite surgical and medical management, he decompensated on Day 11, and TPE was initiated. The patient received a total of 10 TPE treatments. On the fourth day of TPE treatment, he was extubated. Twenty-one days after TPE began, he was ambulating with near normal muscle strength and was discharged. Four months after initial presentation, the patient has normal strength and is working full-time. AHLE has a fulminant course requiring accurate and rapid diagnosis. Successful therapy requires aggressive management of intracranial pressure and immunosuppression. Two other reports of AHLE document successful management with TPE. Each of these patients survived with minimal neurologic impairments. Given the likely immune-mediated nature of this disease, combined treatment of steroids, surgery, and TPE may lead to shorter hospital stays and improved neurologic outcomes. Clinical studies are needed to further study the effect of TPE on neurologic outcome in AHLE.

Successful treatment of a hypothalamic lesion in neuromyelitis optica by plasma exchange

Sirs: Neuromyelitis optica (NMO) is characterized by severe attacks of optic neuritis and myelitis. More than half of patients with NMO are positive for NMO-IgG, a serum autoantibody specific to NMO [3]. In NMO, hypothalamic lesions occasionally develop, and cases with endocrinopathy (hyperprolactinemia/galactorrhea or amenorrhea) have been reported [7, 8]. Recently, therapeutic efficacy of plasma exchange (PE) in some corticosteroid-unresponsive cases of idiopathic demyelinating diseases including NMO has been reported [2, 6, 9]. We report a therapeutic efficacy of PE for a hypothalamic lesion in an NMO-IgG-positive NMO patient totally unresponsive to high-dose intravenous methylprednisolone (HIMP). The patient was a 21-year-old woman who had had total blindness in the left eye and upper-half visual field defect in the right eye (Figure 1, A-1) as sequellae of previous attacks of NMO (a total of ten relapses of optic neuritis and myelitis and normal brain MRI). On 5 April 2004 (Day 1), she complained of deterioration of visual field defect in the right eye and was admitted to our hospital. Neurological examination revealed complete blindness in the left eye and blurred vision with visual defect in the right eye except the nasal lower quadrant, abnormal pupillary light reflex (absent on left and sluggish on right), generalized hyperreflexia, left Babinski sign and painful numbness in her left breast. Galactorrhea was not seen. Brain MRI showed T2-hyperintense lesions in the hypothalamus, medulla oblongata, and cervical cord (C2-8). The hypothalamic lesion partly involved the optic chiasma and pituitary stem (Figure 1, B-1). The hypothalamic and cervical cord (C6-7) lesions were enhanced with gadolinium (Gd). Serum NMO-IgG and antinuclear antibody were positive, and serum prolactine (PRL) level was elevated (49.51 ng/mL). Oligoclonal band were not seen. Although she was first treated with two courses of HIMP therapy (1 g/day, for 3 days) on Day 1-3 and Day 9–11, her visual symptom in the right eye became worse (Figure 1, A-2, A-3) and the hypothalamic lesion remained Gdenhanced (Figure 1, C-1). Serum PRL level became even higher (68.35 ng/ml). We then treated her with PE (2 liters of plasma was exchanged with 5% albumin solution each time.) on Days16, 18, 22, and 26. After two sessions of PE, the visual field in the right eye began to improve and later neared the prerelapse level (Figure 1, A-4). In accordance with the clinical improvement, Gd-enhancement of the hypothalamic lesion disappeared (Figure 1, C-2). Serum PRL level also decreased to 41.57 ng/ml. In our patient, the visual impairment and hyperprolactinemia clearly resolved following PE, although a spontaneous resolution or delayed effect of corticosteroid is not ruled out. Keegan et al. reported six out of ten NMO patients showed improvement following PE [2], but a therapeutic effect of PE on hypothalamic lesions in NMO has not been described. The neuropathological finding of hypothalamic lesions in NMO was demyelination with necrotic changes [7] which was similar to the lesions in the optic nerves and spinal cord of NMO. Hypothalamic involvement could be a under-recognized feature of NMO [5]. The hypothalamic lesion could involve the optic tract as seen in our case. Perivascular deposition of immunoglobulins and activated complements is a characteristic finding of NMO as compared with multiple sclerosis [4]. Moreover, rituximab, anti-CD20 monoclonal antibody targeting pre-B cells and mature B cells, may be effective in NMO [1]. PE’s efficacy in our case, the pathological findings and the rituximab trial strongly suggest that humoral immunity plays a role in the pathogenesis of the hypothalamic lesion in NMO. PE should be considered in treating NMO patients with lesions S. Watanabe AE I. Nakashima I. Miyazawa AE T. Misu AE Y. Shiga K. Fujihara (&) AE Y. Itoyama Dept. of Neurology Tohoku University School of Medicine 1-1 Seiryomachi, Aobaku, Sendai 980-8574, Japan Tel.: +81-22-717-7189 Fax: +81-22-717-7192 E-Mail: fujikazu@em.neurol.med.tohoku. ac.jp

Microparticles Are Active Components of Therapeutic Plasma Exchange: Correlation with ADAMTS13 Activity in Patients with Thrombotic Thrombocytopenic Purpura.

INTRODUCTION: Therapeutic plasma exchange (TPE) is a widely accepted therapy for TTP. A leading hypothesis for its benefit is that TPE replenishes ADAMTS13 with fresh frozen plasma (FFP) and removes inhibitory antibodies. We have reported that endothelial microparticles (EMP) positive for ULvWF are elevated in acute TTP, decline with repeated TPE, and can inhibit ADAMTS13. Presence of platelet microparticles (PMP) in FFP has been described. This led us to the hypothesis that the benefit of TPE is partly due to its effect on microparticles (MP). We investigated the effect of TPE on MP and ADAMTS13 in TTP.METHODS: Nine patients were studied longitudinally during an episode of TTP. Blood samples were obtained upon admission and daily pre- and post-TPE. Additionally, the infused and removed plasma were studied. EMP defined by CD31+/CD42b− (EMP31), CD62E+ (EMP62) and CD62E+/vWF+ (EMPVWF); PMP were defined by CD31+/CD42b+ (PMP42) and CD41+ (PMP41), all measured in platelet-poor plasma by flow cytometry; concentrations are in millions / mL. ADAMTS13 activity was assayed by a FRETS-vWF73 method of Kokame et al [ Br J Haematol 2005; 129:93]. vWF multimers were analyzed following Raines et al [ Thromb Res 1990; 60:201].RESULTS: At admission, TTP patients exhibited very low ADAMTS13 levels, 0–10% of controls (ctl), and elevated EMP31 (2.5 ±0.7 vs. 0.35 ±0.09 ctl) and EMP62 (6.3 ±1.9 vs. 0.25 ±0.07 ctl), both p<0.001. After the first TPE, EMP fell significantly, to 1.76 ±0.85 for EMP31 and 3.4 ±1.3 for EMP62, both p<0.02. Similarly, EMPVWF dropped from 3.7 ±1.8 at admission (ctl = 0.28 ±0.20) to 2.6 ±1.0 after the first TPE, p=0.02. In parallel, ADAMTS13 activity slowly increased with each TPE, finally to near normal, 85 ±22% of ctl. These findings suggest a relationship between ADAMTS13 activity and MP counts. The MP fraction isolated from TTP patients had no detectable ADAMTS13 activity. When the MP fraction from TTP patients was incubated with normal particle free plasma (PFP) for 6hr, then centrifuged to remove MP, a significant fraction of activity was lost (25 ±8%, p=0.02), and no activity could be detected in the resuspended MP. Examination of the vWF multimer composition of the MP fraction of TTP patients exhibited enrichment of large vWF. When we assayed FFP for EMP, PMP and ADAMTS13 activity, we found EMP and LMP comparable to controls (EMP31 = 0.4 ±0.25; EMP62 = 0.31 ±0.2). Only PMP were significantly elevated in FFP (PMP42 = 4.4 ±1.8; PMP41 = 9.0 ±3.2). When we compared ADAMTS13 activity in the MP fraction and the PFP of FFP, the MP fraction accounted for 35 ±12% of the total activity. MP from FFP did not exhibit ULvWF. We consistently observed that immediately following each TPE, both EMP31 and EMP62 were reduced by 15–30%, with a parallel increase in both species of PMP of 10–15%. Concomitantly, EMP and PMP profiles in plasma removed through TPE from TTP patients remained comparable to samples obtained prior to the TPE.CONCLUSION: These results suggest that one action of TPE in TTP is to remove EMP which tend to bind and inactivate ADAMTS13. Thus, the basis of TPE is two-fold: infusion of ADAMTS13 by FFP infusion, and reduction of high levels of inhibitors including inhibitory antibodies as well as EMP.

Therapeutic plasma exchange performed in tandem with hemodialysis for patients with M-protein disorders

M-proteins are monoclonal immunoglobulins or immunoglobulin fragments that aberrantly accumulate in the plasma. Hemodialysis (HD) patients with M-proteins may, under certain circumstances, also need therapeutic plasma exchange (TPE). We employed a protocol for tandem TPE/HD in patients with M-protein disorders. We followed the urea reduction ratio (URR), a measure of the efficiency of HD, to compare the effect of TPE on HD efficiency during tandem procedures versus the efficiency of HD performed as a stand-alone procedure in the same patients. Three men (J.M., R.T., M.M.) underwent 23, 80, and 25 tandem TPE/HD over 3, 17, and 7 months, respectively, almost all in the outpatient setting. Mean whole blood flow rate (in ml/min) was slower during hemodialysis alone than during TPE/HD for J.M. (289 +/- 24 vs. 332 +/- 22, P < 0.0001) and R.T. (310 +/- 20 vs. 367 +/- 15, P < 0.0001) but not for M.M. (395 +/- 65 vs. 404 +/- 62, P = 0.6844). URR was equivalent during hemodialysis alone and during TPE/HD for J.M. (54 +/- 4.2 vs. 58 +/- 1.4, P = 0.3333), R.T. (69 +/- 4.9 vs. 70 +/- 2.5, P = 0.9804), and M.M. (71 +/- 2.4 vs. 67 +/- 1.5, P = 0.1143). J.M.'s renal function recovered sufficiently to permit discontinuation of hemodialysis. R.T. experienced both subjective and objective improvement of his arthritic symptoms. M.M. achieved hemostatic control but ultimately died of amyloidosis. TPE/HD is feasible using disparate pieces of equipment when the therapeutic plasma exchange circuit is connected in parallel with the low-pressure side of the hemodialysis circuit. Our experience illustrates that therapeutic plasma exchange did not adversely impact hemodialysis when the two procedures were performed in tandem.

Retrospective study of plasma exchange in children with systemic lupus erythematosus.

A retrospective review of patients was conducted to evaluate the short-term effect of therapeutic plasma exchange (TPE) in children with active systemic lupus erythematosus (SLE). Between April 1984 and March 2003, 22 children underwent 112 TPE sessions. The median number of daily, double-volume sessions was 6 (range 1-16). Plasma exchange was performed by centrifugation, using 4.5% albumin with fresh-frozen plasma as required. All children were receiving standard immunosuppressive therapy. The predominant clinical features that led to TPE were categorised into systems and outcome was evaluated according to clinical improvement or lack of it. There was benefit for central nervous system and pulmonary manifestations (10 cases, 11 episodes). Of 8 children treated for renal manifestations, 6 achieved good outcomes. Two children became dialysis dependent despite treatment; however, both had been successfully treated with TPE before. Five children received more than one course of TPE. No child died during the procedure and major complications were few. Our data show that TPE can be used as adjunctive therapy in childhood SLE with few complications. Outcome is difficult to measure but in our experience, during the acute phase of illness, TPE appears to be of benefit.

Clinical and experimental study on therapeutic effect of umbilical cord blood transplantation on severe viral hepatitis

To investigate the therapeutic effect of umbilical cord blood transplantation (UCBT) on patients with severe viral hepatitis and on liver lesions in rats. One hundred and fifty three patients with severe viral hepatitis were included in the study between April 1990 and July 2002. The patients were treated with adult plasma transfusion (control), UCBT, plasma exchange (PE) and UCBT combined with PE (UCBT+PE) respectively. The therapeutic effectiveness was evaluated by serial determinations of liver function, lipids and immune function in all patients before and after the treatment. The model of experimental hepatic failure was constructed in SD rats by injecting carbon tetrachloride. Then, the rats were given normal saline, adult plasma or neonate cord blood intraperitoneally. After detection of liver function, the rats were killed and morphological changes of the liver were microscopically observed. UCBT group and UCBT+PE group had much better improvement in liver and immune functions than control group and PE group. The patients in UCBT+PE group had the best clinical efficacy. UCBT was safe and had no side effects. The animal experiment showed significant improvements in liver function and survival rate in neonate cord blood group as compared with adult plasma group. The histopathology of rat's liver indicated that neonate cord blood application could decrease the liver injury and increase hepatocellular regeneration. UCBT demonstrated a good therapeutic effect on severe viral hepatitis and no obvious side effects. Umbilical cord blood can attenuate the liver lesions and reproduce hepatocyte. The treatment of UCBT combined with PE was much better than that of single plasma exchange, thus UCBT can enhance the therapeutic effect of plasma exchange on severe viral hepatitis.