Membrane Therapeutic Plasma Exchange Research Articles

Membrane versus Centrifuge Based Therapeutic Plasma Exchange

Abstract Background Therapeutic plasma exchange (TPE) is an extracorporeal technique that involves separating a large volume of a patient’s plasma from the cellular components of the blood and replacing it with appropriate fluids. In patients with conditions that are induced and/or exacerbated by pathologic factors and toxins circulating in the plasma, TPE can help eliminate symptoms or prevent damage to the organs or systems involved. Aim of the Work To compare between the two methods of plasma exchange “centrifugal therapeutic plasma exchange (cTPE) and membrane therapeutic plasma exchange (mTPE)” as regard efficacy and tolerability. Patients and Methods This study is aprospective observational study. This study conducted plasma exchange unit in Ain Shams university hospitals (Eldemerdash and Ain Shams university specialized hospital). Study period: six months 40 patients. Results In our study we made a comparison between the 2 types as regard total procedure time, plasma removal efficiency, hemostatic parameters and removal efficiency. As regards procedure time, cTPE was longer than mTPE but less in preparation and priming time. As regard plasma removal efficiency, cTPE is higher than mTPE but the difference is not significant. Also, no significant platelets loss with the 2 modalities, but there is significant decrease in hemoglobin post treatment using the 2 modalities. Removal efficiency of IgG and fibrinogen is significantly high but with no significant difference between them. Conclusion This study comparing centrifugal therapeutic plasma exchange (cTPE) and membrane therapeutic plasma exchange (mTPE) revealed that cTPE had significantly shorter treatment time, while mTPE showed comparable patient removal efficiency and adverse event rates. Hemostatic parameter changes varied between studies. Individual device and protocol differences may contribute to these outcomes, emphasizing the need for tailored treatment approaches.

Survival Benefits of Therapeutic Plasma Exchange in Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis.

To summarize the role of therapeutic plasma exchange (TPE) in critically ill adults and children with severe sepsis. A systematic search was performed using the following databases: Medline, EMBASE, CINAHL, and Cochrane from January 1990 till December 2022. Comparative studies of TPE in severe sepsis were selected. Adult and pediatric data were analyzed separately. Eight randomized control trials and 6 observational studies (n = 50,142 patients) were included. Centrifugal TPE was the most common modality (209/280, 74.6% adults and 952/1026, 92.7% children). Every TPE study utilized different volume exchanges. Most TPE sessions (1173/1306, 89.8%) employed fresh frozen plasma (FFP) as replacement fluid and heparin as anticoagulant. Adults with severe sepsis supported with TPE using FFP had lower mortality (risk ratio, RR: 0.64 [95% confidence interval, CI: 0.49, 0.84]) compared to those who did not. In contrast, TPE was associated with increased mortality in septic children without thrombocytopenia-associated multiorgan failure (RR: 2.23, 95% CI: 1.93, 2.57). There was no difference in outcomes in patients supported with centrifugal and membrane TPE. In both populations, patients supported on TPE as a continuous regime had poorer outcome. Current evidence indicates that TPE is a potential adjunct therapy in adults with severe sepsis but not in children.

Retrospective analysis comparing complication rates of centrifuge vs membrane-based therapeutic plasma exchange in the pediatric population.

There are two conventional modalities used to perform therapeutic plasma exchange (TPE): centrifuge TPE (cTPE) or membrane TPE (mTPE). There is limited data on complications with mTPE. We sought to better understand the patient and machine complications of mTPE compared to cTPE. We hypothesize that our protocol for mTPE using heparin anticoagulation is well-tolerated. In this retrospective cohort study of children <21 years of age, we evaluated differences in patient and machine characteristics and complications between cTPE (with citrate anticoagulation) vs mTPE (with heparin anticoagulation). Of the 105 patients who met inclusion/exclusion criteria, 63 received cTPE and 42 mTPE via Prismaflex. Those who used mTPE were younger (4.8 ± 2.8 years vs 15.2 ± 3.7 years, P=.0001) and weighed less (19.5 ± 10.6 vs 71.7 ± 28.5 kg, P=.0001). There were no significant differences in patient-related complications or indications for TPE between the two modalities. Of the 1031 therapies performed,1003 therapies were analyzed (646 using cTPE and 357 using mTPE) due to exclusion criteria. No significant difference in patient complications were detected between groups. Machine-related complications were infrequent in both approaches. More circuits clotted during mTPE than during cTPE (6.7% [24/357] vs 0% [0/646]; P < 0.001). Although we use mTPE in smaller children, we showed low rates of complications that were not statistically different from cTPE performed in older children. While the overall rate of circuit clotting using mTPE was low, it occurred more commonly than with cTPE.

Regional Hypertonic Citrate Anticoagulation in Membrane Therapeutic Plasma Exchange: A Case Series.

Rationale:Protocols for regional citrate anticoagulation with the hypertonic 4% trisodium citrate solution have been recently described as an anticoagulation strategy during membrane therapeutic plasma exchange (mTPE). The effect of citrate in the patient’s systemic hemostasis is negligible, thus regional citrate anticoagulation application is advantageous in circumstances in which heparin-based protocols are deemed unsafe for patients with a high risk of bleeding. The downsides of using hypertonic citrate solutions are mainly hypocalcemia and hypernatremia that ultimately can cause adverse clinical events.Presenting concerns of the patient:(1) A 57-year-old Caucasian female with a history of active vaginal bleeding secondary to endometrial hyperplasia. She had a history of antiphospholipid syndrome, and systemic lupus erythematosus with marked refractory autoimmune thrombocytopenia. Her platelet count was persistently below 4,000/mm3 even after different immunosuppressive regimens and daily platelet transfusions. (1) A 70-year-old Caucasian female was hospitalized presenting acute kidney injury stage 3 due to rapidly progressive antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, however without the need for renal replacement therapy. At admission, serum creatinine (sCr) was 3.56 mg/dL (normal range: 0.53-1.00 mg/dL). Her baseline sCr was 0.8 mg/dL obtained 6 months earlier. Chest tomography revealed bilateral masses compatible with granulomatous lesions and no signs of alveolar bleeding. Since severe cases of ANCA vasculitis involving the lungs may evolve with alveolar hemorrhage, heparin was avoided.Diagnoses:(1) Systemic lupus erythematosus-associated autoimmune thrombocytopenia and (2) ANCA-associated vasculitis with kidney and lung involvement.Interventions:Herein, we describe a case series of 12 consecutive mTPE treatments in 2 different patients using regional 4% trisodium citrate anticoagulation.Outcomes:All the sessions were uneventful, presented only minor electrolyte imbalances, and were effectively completed without early interruptions due to clotting of the plasmafilter.Teaching points:In our 2 cases, extracorporeal regional citrate anticoagulation was successful in optimizing plasmafilter patency without bleeding events in 2 high-risk patients using established protocols for the citrate and calcium infusions.

PMD25 COMPARING ECONOMIC IMPACT OF CENTRIFUGAL AND MEMBRANE THERAPEUTIC PLASMA EXCHANGE IN A SINGLE INSTITUTION IN THAILAND

Therapeutic plasma exchange (TPE) is one of the therapeutic apheresis procedures where it removes pathogenic substances that cause the underlying disease such as autoantibodies and circulating immune complexes from the plasma. TPE continued to play a key role in management of various diseases and remained as the treatment choice as per 2016 guidelines of the American Society of Apheresis for Guillan-Barré syndrome, ANCA associated rapidly progressive glomerulonephritis, thrombotic thrombocytopenic purpura and renal transplantation, to name a few. TPE can be performed using two techniques; membrane or centrifugal. This study examined the cost associated with these techniques from payer perspective. TPE utilization and cost data were collected from nephrology and hematology department in Rajavithi Hospital, Bangkok. A cost benefit analysis model was developed using micro-costing approach with the following cost component; device acquisition, maintenance, consumables, venous access, replacement fluids, labor. Data on procedure efficiency and clotting frequency were sought from published literatures. Clotting was defined as requiring filter replacement to continue procedure. The model assumed similar clinical outcome in these techniques. A total of 96 TPE procedures were performed in Rajavithi hospital. Out of these, 72 procedures were used membrane plasma filter for plasma exchange. The estimated cost per procedure for centrifugal and membrane TPE was USD 285 (THB 8942), rounded to nearest integer, and USD 982 (THB 30,797), respectively. Plasma exchange with membrane technique cost the payer additional USD 63,864 (THB 2,002,759) annually. Clotting of the plasma filter resulted in USD 230 (THB 7211) per procedure. The economic evaluation between these two plasma exchange techniques showed centrifugal TPE had a better cost benefit than membrane TPE. For a hospital with similar characteristics, we expect positive economic impact with application of centrifugal TPE.

PMD11 MEASURING THE ECONOMIC IMPACT OF THERAPEUTIC PLASMA EXCHANGE: A SINGLE INSTITUTION STUDY IN XIAMEN, CHINA

Therapeutic plasma exchange (TPE) is a procedure that removes pathogenic substances of high molecular weight such as antibodies, endotoxins, circulating immune complexes and cholesterol-containing lipoproteins from plasma. During TPE procedure, patient blood is drawn into the medical device that separate and remove plasma from cellular component. The removed plasma goes into the waste bag and replaced with plasma substitute fluid, which are then returned to the patient. According to 2016 guidelines of the American Society of Apheresis (ASFA), TPE is recommended first line treatment in various disease category; neurology, transplantation, intensive care settings, renal and hematology. Plasma exchange can be performed using centrifugal or membrane filtration method. This study assessed the cost associated with these techniques from payer perspective. TPE utilization and cost data were collected from nephrology and hematology department, The First Affiliated Hospital, Xiamen, China. A cost benefit analysis model was created on Excel spreadsheet using micro-costing approach with the following cost component; device acquisition, maintenance, consumables, venous access, replacement fluids, labor. Data on procedure efficiency and clotting frequency were sought from published literatures. Clotting was defined as requiring filter replacement to continue procedure. The model assumed similar clinical outcome in these techniques. A total of 92 TPE procedures were performed annually with over half of the patients (67.3%) used centrifugation method. The estimated cost per procedure for centrifugal and membrane TPE were USD 557 (CNY 3,854), rounded to nearest integer, and USD 1321 (CNY 9138), respectively. Payer is expected to save USD 764 (CNY 5284) for every TPE performed using centrifugal compare to membrane method. The economic evaluation between these two plasma exchange methods showed centrifugal TPE had a better cost benefit than membrane TPE.

PMD5 ECONOMIC BENEFIT OF CENTRIFUGAL VERSUS MEMBRANE THERAPEUTIC PLASMA EXCHANGE: A SINGLE INSTITUTION EXPERIENCE IN VIETNAM

Therapeutic plasma exchange (TPE) is a procedure that removes pathogenic substance that cause the underlying disease such as harmful antibodies – immune complexes, cytokines or endotoxins from patient’s plasma. In a typical TPE procedure, 1 to 1.5 plasma volumes are removed and replaced with another fluid (human albumin or fresh frozen plasma). In the American Society for Apheresis guidelines, TPE is recommended first line therapy in management of various renal, hematological and neurological diseases. TPE can be performed using two categories of devices; membrane or centrifugal. This study assessed the cost associated with these techniques from public payer perspective. TPE utilization and cost data were collected from nephrology and hematology department, Hue Central Hospital, Vietnam. A cost benefit analysis model was created on Excel spreadsheet using micro-costing approach with the following cost component; device acquisition, maintenance, consumables, venous access, replacement fluids, labor. Data on procedure efficiency and clotting frequency were sought from published literatures. Clotting was defined as requiring filter replacement to continue procedure. The model assumed similar clinical outcome in these techniques. On average, 20 TPE procedures were performed annually with equal proportion of patients on both techniques. The estimated cost per procedure for centrifugal and membrane TPE were USD 856 (VND 19,984,545), rounded to nearest integer, and USD 1115 (VND 26,046,045), respectively. For every 10 procedures performed on centrifugal technique, payer is expected to save USD 2595 (VND 60,615,000). The economic evaluation between these two plasma exchange techniques showed centrifugal TPE had a better cost benefit than membrane TPE. For a hospital with similar characteristics, we expect positive economic impact with application of centrifugal TPE.

PMD12 UNDERSTANDING THE ECONOMIC IMPACT OF THERAPEUTIC PLASMA EXCHANGE: A SINGLE INSTITUTION STUDY IN PUNE, INDIA

Therapeutic plasma exchange (TPE) is a procedure that removes large volume of plasma from a patient. Through the bulk removal and replacement of plasma, pathogenic substances that cause underlying disease such as antibodies, endotoxins, circulating immune complexes and cholesterol-containing lipoproteins were removed. It is a common treatment modality in management of various renal, hematological and neurological diseases. Plasma exchange can be performed using centrifugal (c) or membrane (m) filtration method. This study assessed the cost associated with these techniques from public payer perspective. TPE utilization and cost data were collected from nephrology department, Deenanath Mangeshkar Hospital, Pune, India. A cost benefit analysis model was created on Excel spreadsheet using micro-costing approach with the following cost component; device acquisition, maintenance, consumables, venous access, replacement fluids, labor. Data on procedure efficiency and clotting frequency were sought from published literatures. Clotting was defined as requiring filter replacement to continue procedure. The model assumed similar clinical outcome in these techniques. Sensitivity analysis was conducted with increase number of TPE procedures on centrifugal technique. A total of 166 TPE procedures were performed annually; membrane (90%) and centrifugal (10%). In the sensitivity analysis, converting 90% mTPE to cTPE, cost per procedure for centrifugal and mTPE was estimated at USD 261 (INR 18,117), rounded to nearest integer, and USD 371 (INR 25,763), respectively. Plasma exchange with membrane technique cost the payer additional USD 110 (INR 7,646) for each TPE procedure. Additional savings of USD 29 (INR 2000) was expected for each cTPE procedure with peripheral access. The projected annual cost savings with predominant use of centrifugal technique was USD 33,210 (INR 2,305,392). The economic evaluation between these two plasma exchange methods showed centrifugal TPE had a better cost benefit than membrane TPE.

PMD20 CENTRIFUGAL VERSUS MEMBRANE THERAPEUTIC PLASMA EXCHANGE: SINGLE CENTER COST BENEFIT ANALYSIS IN THAILAND

Therapeutic plasma exchange (TPE) is a common treatment modality in management of various renal, hematological and neurological diseases in which large volume of plasma is removed and replaced with replacement fluid. Through TPE, pathologic substances that cause the underlying disease such as inflammatory mediators; autoantibodies, complement components and cytokines are eliminated and substantially improve patient quality of life. TPE can be performed using two categories of devices; membrane or centrifugal. We aimed to analyze the cost associated with these techniques from payer perspective. We estimated cost of membrane and centrifugal TPE based on 250 procedures performed annually in Prasat Neurological Institute, Thailand. Micro-costing approach was applied according to local clinical practice, and other probabilities were derived from published literature. Cost component includes device acquisition, maintenance, consumables, procedure time, plasma replacement fluids, clotting events and labor. The model assumed similar clinical outcome in these techniques. Overall estimated TPE cost per procedure using membrane and centrifugal techniques were USD 380 (rounded to nearest integer) and USD 241, respectively. We projected an annual savings of USD 34,759 (36%) for centrifugal TPE application in 250 procedures. The difference in the total time (set-up and procedure) for both techniques (mTPE, 150 minutes vs cTPE, 96 minutes) may be minimal for each procedure, however that translate to 6 weeks staff time saved per year for each centrifugal TPE procedure. We demonstrated that centrifugal TPE had a better cost benefit ratio than membrane TPE.

PMD21 COST BENEFIT ANALYSIS FOR CENTRIFUGAL VERSUS MEMBRANE-BASED THERAPEUTIC PLASMA EXCHANGE

Therapeutic plasma exchange (TPE) is applicable in a variety of clinical indications. It can be performed through centrifugal systems (cTPE) and membrane devices (mTPE). Both come with different costs, adverse events, procedure times and plasma removal efficiency. The objective of this study is to perform a cost benefit analysis comparing cTPE and mTPE through the lens of a health system payer. Drivers of cost and actual cost data were collected through a systematic literature review on PubMed and the ISPOR Scientific Presentations Database. All retrieved costs were adjusted and discounted for the year 2018. In terms of health outcomes related to the primary indication of treatment, cTPE and mTPE demonstrated equal effectiveness. The most important cost drivers identified for both TPE systems were: device acquisition costs, maintenance costs, disposable costs, procedure/staff time, plasma replacement fluids, catheter type (central vs peripheral), clotting events, and the costs of adverse events. On a basis of 250 TPE procedures during a single year the total cost for the health system payer was € 172 lower for cTPE vs mTPE. Resulting in a potential yearly saving of € 43.000 per hospital unit where TPE is performed. In terms of staff time 6 weeks of FTE time per year could be saved by favoring cTPE over mTPE. In the above tested scenario, centrifugal TPE had a better cost benefit ratio than membrane TPE. Increased utilization of cTPE versus mTPE is likely to results in cost savings for apheresis units and their payers.

Membrane therapeutic plasma exchange with and without heparin anticoagulation.

Administration of an anticoagulant during therapeutic plasma exchange (TPE) is necessary to avoid circuit clotting and impaired treatment effectiveness. Citrate is the preferred anticoagulant for apheresis worldwide, and unfractionated heparin (UH) is the second most preferred, yet there are only a few published studies regarding the use of UH during TPE. There are even fewer studies regarding the use of low-molecular-weight heparin (LMWH) and TPE performed without anticoagulation. We retrospectively analyzed the database of the Department of Nephrology at Zagreb University Hospital Center from 1982 to 2014 to test the safety of various heparin anticoagulation in TPE. We grouped procedures according to anticoagulation type (UH, LMWH, and no anticoagulation) and compared differences in the use of anticoagulants during our study period, patient populations, replacement fluids, and complications. Complications were recorded during 11.1% of the 9,501 procedures. The incidence of any recorded complication was significantly higher in the LMWH group (21.2%) compared to the group with no anticoagulation (16.3%) and the UH group (9.5%) (P < 0.001). Similarly, the blood clotting in the extracorporeal circuit was most common in the LMWH group (LMWH, 12.0%; no anticoagulation, 6.3%; UH, 2.4%; P < 0.001). Incidents of bleeding complications were very low and occurred during or after 13 TPE sessions (0.1% of all procedures). Our findings indicate that TPE procedures can be conducted safely with UH and, when necessary, without anticoagulation. The use of LMWH was associated with more complications when compared with use of UH and to TPE done without anticoagulation. Further studies are necessary to study its use during TPE procedures.