Plasmapheresis Procedure Research Articles

Efficacy and Safety of Therapeutic Plasma Exchange in Children with Neuroimmunological Disorders: A Limited Unicentral Study.

Therapeutic plasma exchange (TPE) is a plasmapheresis procedure whose Safety data for pediatric neuro-immunological disorders (PNID) is confined. The present research documents TPE's safety and feasibility data in these conditions. The current study involved six distinct groups of patients with PNID undergoing TPE: neuromyelitis optic spectrum disorder (NMOSD), autoimmune encephalitis (AIE), acute disseminated encephalomyelitis (ADEM), multiple sclerosis (MS), Guillain-Barre syndrome (GBS), and optic neuritis (ON). This study documented complications related to each TPE process. In addition, TPE's efficacy was studied in these patients. The present study recorded adverse effects in 18 patients with PNID that received 121 TPE cycles: five cycles (4.13%) in MS, three (2.48%) in AIE subgroup, one (0.82%) in ADEM, and two (1.65%) in GBS. No severe complications were observed among the patients. Patients with PNID tolerated therapeutic plasma exchange, which was a safe process.

Use of Plasmapheresis in Heparin Induced Thrombocytopenia in Patients Undergoing Urgent Cardiac Surgery

Abstract Heparin Induced Thrombocytopenia (HIT) is a potentially life-threatening but uncommon disease process characterized by IgG antibodies that recognize platelet factor 4/heparin immune complexes causing thrombocytopenia and thrombosis. Although therapeutic plasmapheresis (PLEX) appears to be effective, protocols regarding how and when to institute PLEX remain elusive. At our institution, we put together a standardized approach to assess the interventional success across patients that included 1 plasmapheresis procedure per day over 4 days, processing one plasma volume and using thawed plasma as the replacement fluid. Treatment effectiveness was evaluated by pre- and post-interventional HIPA OD levels and platelet count. Treatment aim was to decrease the HIPA OD to less than 0.6 and obtain a normal platelet count. The aim of this study was to design a protocol for PLEX to address urgent need for patients with HIT for which heparin is planned for intraoperative cardiac surgery requiring cardiopulmonary bypass (CPB) anticoagulation. We retrospectively examined the medical records of 2 HIT-positive patients who underwent PLEX prior to cardiac surgery at our large quaternary care hospital. Both patients had a 4Ts score of 5, with a medium probability of disease. One patient's HIT was confirmed by a positive serotonin release assay (SRA). The second patient had persistently negative confirmatory test but was deemed clinical HIT. The first patient is a 53-year-old female, who was admitted for mitral valve replacement, aortic valve replacement, and tricuspid valve repair. She was confirmed HIT by positive SRA. Three sessions of PLEX were performed on consecutive days. Her HIPA (heparin induced platelet antibody) O.D. value decreased from 1.925 to 0.534 and platelet counts normalized. The second patient is a 73-year-old male, who was admitted for LVAD implantation and LV thrombus resection. Two sessions of PLEX were performed on consecutive days. His HIPA O.D. value deceased from 1.261 to < 0.4 (negative) and platelet counts normalized. For both patients, the last PLEX procedure was performed the day of surgery, and the cardiac surgical procedure was completed successfully. Based on these 2 patients, we have proposed a protocol for PLEX in HIT patients as follows: daily plasmapheresis x 4 days will be performed until the OD has decreased to less than 0.6 and platelet count has normalized. Each plasmapheresis will consist of the processing of one plasma volume, using thawed plasma as the replacement fluid. The last plasmapheresis will occur on the day of surgery prior to surgery. Further assessment will be performed if the targeted parameters have not been met by the 4th plasmapheresis procedure. In conclusion, we present 2 patients with HIT who benefitted from PLEX prior to cardiac surgery under CPB. We will adopt the protocol used for these 2 patients as our standard of practice moving forward.

Plasmapheresis in Myasthenia Gravis Crisis

Introduction: Myasthenic crisis is the most lethal complication of myasthenia gravis. Referral to an intensive care unit is crucial in managing the myasthenic crisis. Hereby, we report a case of a myasthenic crisis in a 30-year-old female who underwent plasmapheresis. The patient underwent a 12-hour procedure for plasmapheresis and was discharged to a normal ward the next day. Although plasmapheresis is costly, its efficacy should be considered as the main treatment for myasthenic crisis.
 Case Illustration: Female, 30 years old, weighed 60 kgs, with myasthenia crisis. The patient came to an emergency department and was then intubated before being admitted to the intensive care unit. The physical diagnostic was normal and laboratory findings were leukocytosis. The patient was treated with normal saline, antibiotics, high-dose corticosteroids, and pyridostigmine. The patient was done plasmapheresis with synchronized intermittent mandatory ventilator mode. The patient was examined every 30 minutes. The physical examinations were relatively normal. The plasmapheresis procedure was ended in 12 hours.
 From the literature, plasmapheresis was found to have significant results for myasthenia gravis compared to conventional therapy because of its blood separation technique to remove autoantibodies. The next day patient was extubated with normal physical examinations and normal laboratory findings. The patient then moved from the intensive care unit to the normal ward and outpatient on the third day of hospital stay. The patient was given oral medicine that included antibiotics, corticosteroids, and pyridostigmine.
 Conclusion: From this case, we can see that plasmapheresis therapy has a really good outcome compared to other conventional therapy. However this therapy is expensive, so most healthcare providers don’t cover the payment. Hopefully, most hospitals and healthcare providers can cover up for this treatment to save many myasthenia gravis crisis.
 
 Keyword: Intensive Care Unit; myasthenic crisis; myasthenia gravis; plasmapheresis; treatment efficacy

Hardware Plasmapheresis Use for Correction of Aging Biomarkers in Healthy Patients Aged 40–60 Years: an Original Study

INTRODUCTION. Due to the demographic aging of the population, the problem of treatment of age-related diseases and prevention of premature aging in modern healthcare has become particularly urgent. One of the most promising approaches is the impact on the molecular mechanisms of aging, including the activation of adaptive systems and suppression of pathological processes in the body. Methods of extracorporeal hemocorrection have proved to be a good idea in this respect.
 AIM. To evaluate the effectiveness and safety of hardware plasmapheresis as a technology for correcting aging biomarkers.
 MATERIAL AND METHODS. A technique of therapeutic plasmapheresis use was introduced for the correction of aging biomarkers. Twenty-four participants (male and female) aged 4060 years with an elevated level of one or more aging biomarkers underwent a course of therapeutic plasmapheresis in the daytime hospital. All participants underwent four procedures of therapeutic hardware plasmapheresis once every 3 days with 30 % volume of circulating plasma followed by replacement with colloid (5 % albumin solution) and crystalloid solutions (saline solution) in a 1:3 ratio or only crystalloid solutions.
 RESULTS AND DISCUSSION. A comparative evaluation of aging biomarkers before the procedure and 17 and 30 days after hardware plasmapheresis showed that therapeutic plasmapheresis affects the levels of human aging biomarkers in blood. A significant decrease in the levels of such biomarkers as homocysteine, urea, gamma-glutamyl transpeptidase, alkaline phosphatase, creatine phosphokinase, cholinesterase, and uric acid was shown. No significant differences were detected when we performed a comparative assessment of biochemical blood parameters following plasmapheresis with or without albumin replacement on biochemical blood parameters. Stable hemodynamic parameters during plasmapheresis and the absence of adverse reactions in patients confirm the safety and tolerability of the therapeutic plasmapheresis procedure.
 CONCLUSION. Implementing this technique into clinical practice will allow the development of approaches to etiotropic therapy of many chronic age-related pathologies. These treatments have the potential to increase life expectancy and improve its quality.

Complications of Therapeutic Plasma Exchange in pediatric patients: An experience at a tertiary care hospital.

To find the incidence of various complications of therapeutic plasma exchange (TPE) in ICU admitted children and to determine their association with age, gender, blood group and diagnosis of the patients. In this observational study, data of 24 patients who underwent 125 sessions of TPE was collected from the Pediatric Intensive care unit (PICU) and Hematology department of The Children's Hospital, Lahore from December 2020 to November 2021. Age, gender, blood group, indications and complications observed during and after the TPE procedure were documented on a pre-designed proforma. The data was analyzed by using SPSS version 23. Quantitative variables were presented in the form of mean and standard deviation. Qualitative variables like gender, blood groups, indications and complications of plasmapheresis were presented as frequency and percentage. Chi square test was applied for comparison of variables. Among the 24 patients, 45.8% were of age group five to ten years with mean age of 7.58 years± 2.04 years and male to female ratio of 0.84:1. Guillain-Barré syndrome (GBS) and Neuromyelitis Optica spectrum disorder (NMO-SD) were the most prevalent among the patients who underwent TPE. Most common complication was hypotension (44.9%), others were febrile reactions (11.6%), unstable vital signs (14.5%) and allergic reactions (24.6%). Blood group, clinical condition and diagnosis of the patient showed significant association with the incidence of TPE related complications. The majority of problems caused by TPE are considered to be minor. Sudden fall in blood pressure, pruritus, urticarial rash and fever are the common adverse consequences among pediatric patients. Blood group and diagnosis of the patient can determine the development of such complications during plasmapheresis procedure.

Myasthenia gravis masquerading as amyotrophic lateral sclerosis: a case report

Myasthenia gravis is an autoimmune disease that causes weakness in the skeletal muscles. It is considered to be a relatively rare disease. Most commonly the first symptoms are associated with ocular muscle weakness resulting in ptosis and/or diplopia that may be progressive during the periods of muscle exertion and resolve with rest. However, any skeletal muscle group may be affected leading to the variability of clinical symptoms and potential challenges in diagnostics. We present a case report of a 62-year-old male that initially presented with bulbar symptoms and unintentional weight loss, with atypical findings in electromyography study (the absence of decrement amplification in a combination of spontaneous muscular activity) – suggestive for amyotrophic lateral sclerosis (ALS) diagnosis. After a thorough investigation the diagnosis of ALS was not confirmed but myasthenia gravis was highly suspected and anti-MuSK antibodies came positive. The patient was prescribed Pyridostigmine, Prednisolone and underwent plasmapheresis procedure which led to significant relief of the symptoms.

EVALUATION OF CLINICAL AND LABORATORY FINDINGS OF THERAPEUTIC PLASMAPHERESIS IN CHILDREN

Therapeutic plasmapheresis is an extracorporeal treatment method. The abnormal component of the patient's plasma is removed from the blood and replaced with the remaining blood components with a selected replacement fluid. We aimed to evaluate the demographic characteristics, procedure indications, procedure methods, differences between pre- and post-procedure laboratory parameters, and procedure-related complications of pediatric patients who underwent therapeutic plasma exchance (TPE). Pediatric patients who underwent therapeutic plasmapheresis in Adana City Training and Research Hospital between 2018-2021 were included in our study. In this period, the number of pediatric patients who underwent therapeutic plasmapheresis was 61, and the total number of procedures was 238. The data of the patients were obtained from the files of the apheresis unit and the hospital registry system by retrospective analysis. Statistical analysis of the study was made with the SPSS v20 program. 25 patients were female, 36 patients were male. Youngest patient was 6 months old and eldest was 17 years old. Patients weight range was between 5 and 104 kilograms. 191 of the procedures were TPE, 47 of them were lipid apheresis. The most common indications were hepatic failure, familial hyperlipidemia, neurological disorders, hematological disorders, sepsis with MODS and intoxications. 119 transactions were in ASFA category-1. Complications were observed on 59 (%24,8) procedures. The most common complications are; vascular access releated (obstruction) (21/59), hypotension (11/59), urticaria (7/59), technical malfunctions (7/59) and hypocalcemia (4/59). No exitus was observed due to the procedures. Therapeutic plasmapheresis procedure doesn't cause serious undesirable changes in laboratory values ​​and serious complications are rare. Therapeutic plasmapheresis can be safely applied to pediatric patients in appropriate indications by making necessary adjustments.

Severe and long-lasting alteration of albumin redox state by plasmapheresis

Plasmapheresis (PE) is an established form of therapeutic apheresis (TA). Purpose of this longitudinal prospective single center study was to investigate the effect of PE on albumin redox state (ARS), as infusion of commercial albumin during PE may alter albumin oxidation which has an impact on its functional properties and oxidative stress level. 43 subjects with autoimmune-mediated neurological disorders were included. 20 subjects in the experimental group received five treatments of PE. 13 subjects received five treatments of immunoadsorption and 10 subjects received no TA as controls. ARS was determined before and after TA and 12 days after the last TA by fractionating it into human mercaptalbumin (HMA), human non-mercaptalbumin 1 (HNA-1), and human non-mercaptalbumin 2 (HNA-2) by high-performance liquid chromatography. Irreversibly oxidised HNA-2 increased over the course of five PE treatments from 2.8% (IQR 1.3–3.7%) to 13.6% (IQR 10.9–15.9) (P < 0.01) and remained elevated 12 days after the last PE procedure (7.7% IQR 7.1–10.5, P < 0.05). The study showed for the first time that PE exerts a severe and long-lasting alteration on ARS indicating a new adverse effect of PE, that may influence oxidative stress level.

Case Report: Serial Cases: Prolongation of High Immunoglobulin G Level in Repetitive COVID-19 Convalescence Plasma Donor in Saiful Anwar Hospital Malang, Indonesia

BackgroundConvalescent plasma therapy is expected to be a promising alternative to supportive therapy during the SARS-CoV-2 pandemic outbreak. Altered immune response in repetitive convalescent plasma donors has not been widely studied. This case series was reported to analyze the patterns of immune responses and the factors that might influence them in repetitive convalescent plasma donors and increase awareness of COVID-19 survivors to donate their convalescent plasma.Cases IllustrationThere were five repetitive donors who were eligible as convalescent plasma donor requirements. It was found two donors who showed increment of anti-SARS-CoV-2 IgG level after donation and two others who showed persistent anti-SARS-CoV-2 IgG level more than two months after recovered.DiscussionThere was a difference in immune response in survivors who have the probability of being exposed to same antigens with survivors who did not, where the group of survivors who are at risk of exposure to antigens after recovery could trigger anamnestic immune response that can increase antiSARS-CoV-2 IgG levels. The other factor that influence the prolongation of anti-SARS-CoV-2 IgG levels are the possibility of neutralizing antibodies in plasma upregulation.ConclusionImmunological phenomenon in SARS-CoV-2, both in survivors and convalescent plasma donors, have not been widely observed and studied. From the case series discussed above, it can be concluded that convalescent plasma donation does not yet have strong evidence of decreasing levels of specific antibodies against SARS-CoV-2 and plasmapheresis procedure is safe to be done without reducing the protective effect of donor antibody post-plasma donation.

Optimising plasmapheresis procedure: The role of plasma unit weight setting

The AUSL-IRCCS of Reggio Emilia Transfusion Unit operates in two blood donor centers. Plasmapheresis protocols and machines are identical in both centers, except for the final unit weight setting: 700 g in Center 1 and 720 g in Center 2. Within a wider study to assess the anticoagulant content in plasma units through proton nuclear magnetic resonance, we compared the efficiency of the two settings. We analyzed 215 and 100 consecutive samples from Centers 1 and 2, respectively. We collected processed blood volume, net plasma collected and anticoagulant volume in the plasma units. In our experience, setting the machine at 720 g instead of 700 g was associated with a small increase in plasma content of the final unit (only 4 mL), but implied an increase of more than 100 mL of the total processed blood and a higher amount of anticoagulant in the unit. On the contrary, the difference in donor's reinfused anticoagulant was negligible.Our findings come from an observational study suggesting that, in view of a minimal advantage in terms of collected net plasma, there might be relevant disadvantages for the donor in prolonging plasmapheresis over 700 g. Since observed differences may be attributed to confounding factors, we recommend always checking the marginal efficiency of the procedure when the balance target value of the setting is increased. Randomized cross-over studies are needed to find the optimal target weight for plasma units. These studies could also help defining personalized plasmapheresis procedures, thus further optimizing donor safety.

Offering new and returned donors the option to give plasma: implications for donor retention and donor adverse events

In 2018, Australian Red Cross Lifeblood changed its plasmapheresis eligibility criteria to allow donors to donate plasma without the requirement of a prior successful whole blood donation. This study evaluated the impact of this policy change on donor retention and donor safety. All donors who had attempted to give their first plasma or whole blood donation from January to June 2018 were included in this retrospective cohort study. Donor characteristics and adverse events were analysed for this index donation, and the cohort was followed for 18months to analyse time to return, subsequent donation frequency and predictors of return. Male and younger donors provided a significantly greater proportion of first donation plasma than females and older donors. New donors who gave plasma had the highest rate of donor adverse events, including vasovagal reactions and phlebotomy injuries. Nevertheless, donor retention was not affected, with more new donors returning and at a greater subsequent donation frequency after a plasma donation compared to new donors donating whole blood. First-time plasma donors who had previously donated whole blood, however, had greater and quicker rates of return, and more subsequent donations. Offering new donors the option to give plasma had a positive effect on donor return and subsequent donation frequency. Removing the requirement of a prior whole blood donation is a viable way to increase plasma collections although the combined effect of new donor status and plasmapheresis procedure on adverse event risk needs to be considered.

Terapeutyczna plazmafereza w praktyce klinicznej

Plasmapheresis is a procedure which performed for appropriate indications contributes to the improvement of patients’ clinical condition and treatment prognosis. Plasmapheresis is also one of the therapy methods used in acute phases of autoimmune disorders. Hereby, the theoretical and practical possibilities offered by therapeutic plasma exchange in supportive treatment of various medical conditions are described. The article is based on the reports of procedures performed at the Department of Transfusion Medicine of the Institute of Hematology and Transfusion Medicine in the period 2016–2017. It presents the mechanism of plasmapheresis, the methods used in everyday practice as well as the effect of the procedure on blood components and plasma. It also emphasizes the significant role of the nurse in the plasmapheresis procedure particularly in relation to possible complications and adverse reactions.

Treatment of a patient with relapsing hypertriglyceridemia-induced necrotizing pancreatitis: a case report

This case report demonstrates a clinical treatment tactic of a 39 y.o. patient with acute necrotizing pancreatitis. The peculiarity of the disease course is its cause – hypertriglyceridemia associated with poorly managed type 2 diabetes. Within 5-year interval in 2007 and 2012 respectively, the patient suffered two attacks of severe necrotizing pancreatitis. In 2007 he had necrotizing noninfectious pancreatitis, and in 2012 – infectious necrotizing pancreatitis requiring open sequestrectomy. The patient underwent efferent therapy methods such as hemosorbtion and plasmapheresis in combination with standard treatment scheme. The post-operative period was marked by arrosive hemorrhage, subphrenic abscess, ligature fistulas and giant post-operative hernia. During all period of observation (2007 – 2017), the patient was suffering hypertriglyceridemia (blood test as of December 22, 2016 demonstrated high level of triglycerides – 21.92 mmol/L), which required the periodical plasmapheresis procedure. Despite two attacks of severe acute necrotizing pancreatitis, five years later the patient’s life quality according to SF-36 questionnaire is approaching normal.

Procoagulant impact of the plasmapheresis procedure on coagulation state of collected plasma.

Plasmapheresis is a group of extracorporeal techniques that involve removal of whole blood, separation of plasma from cellular elements and partial return of blood components (at least the red blood cells) into the circulation. It is widely used for therapy and plasma collection with the purpose of either further transfusion or manufacture of medicines. Plasmapheresis necessarily involves significant contact of blood with inner surfaces of the plasmapheresis kit, so the possibility of contact activation of coagulation is a concern with regards to both donor safety and quality of the product obtained. Although initial1 (and some recent2) studies did not detect any noteworthy coagulation changes in donors’ blood, this view was challenged by other reports. Using a more sensitive global assay of thromboelastography, hypercoagulation was found following various apheresis procedures3. Some researchers found that there could be additional pro-coagulant mechanisms for donors who often undergo apheresis4, while others did not detect any differences in intensive donors5. Dangerous or even fatal venous and arterial thromboses were reported in individual cases after large-volume donations, usually when donors had pre-disposing risk factors6,7. Nevertheless, existing screening processes that plasma donors undergo do not take into account blood coagulation. There is even less information about the effect of plasmapheresis on the coagulation status of the collected plasma. Although the composition of such plasma with regard to coagulation factors and activation markers has been evaluated by some researchers8–10, we are not aware of any attempts to systematically compare the coagulation system in collected plasma with that of the original donor plasma. Here we carried out such a comparison using three global assays of the coagulation system: thrombin generation, thromboelastography and thrombodynamics together with clotting assays and other methods. Global assays that are increasingly used these days aim to mimic coagulation in vivo better11 and are particularly noteworthy for their ability to detect pro-coagulant changes, unlike traditional clotting assays12–15. Using these assays we found significant changes in coagulation occurred as a result of the plasmapheresis procedure.

Plasmapheresis Is an Effective Approach Preventing Clinically Significant Tumor Lysis Syndrome during Induction Therapy in AML Patients with Hyperleukocytosis

Introduction. Most studies have found that hyperleukocytosis (HL >100*109/l) is a poor prognostic factor in acute myeloid leukemia (AML). It is diagnosed in 5-13 % of cases and is more common in AML with monocytes’ differentiation (M4, M5), as well as in cases with poor prognostic molecular markers, such as FLT3-ITD and others.According to the literature the early (during the first week) mortality in AML due to HL may reach 90%. The main cause of death are leukostasis, leading to neurological symptoms, respiratory distress syndrome (RDS) with lung lesions, disseminated intravascular coagulation (DIC) syndrome with the development life-threatening bleedings and massive tumor lysis syndrome during induction therapy.Aim. National Research Center for Hematology (NRCH) has initiated a prospective clinical study aiming to develop a feasible clinical approach preventing severe tumor lysis syndrome during induction in AML patients with initial WBC >100*109/l by using serial plasmapheresis (PA).Patients and Methods. From Jan 2010 till June 2014, 92 patients with de novo AML were treated in the NRCH according to AML-10 protocol (ClinicalTrials.gov Identifier: NCT01587430). Initial white blood cell (WBC) count more than 100x109/l was detected in 18 patients (19,5%): median age - 38 y (17-56yy), M/F - 10/8, WBC - 130x109/l (100-408x109/l), LDH -1765 µ/l (720-6653). 2 patients were in the favorable, 13 – in the intermediate, 2 - in the poor cytogenetic risk group. 83,3% (15/18) patients had hepatosplenomegaly and lymphadenopathy, 38.8 % (7/18) - gingival hyperplasia, 16,6 % (3/18) - neuroleukemia, 16,6% (3/18) - skin leukemids. All patients had infectious complications at diagnosis.Lung infiltrates due to leukostasis were revealed - in 77,8% (14/18), including 5 patients (27,8%) with RDS; neurological symptoms (headache, blurred consciousness) - in 33,3% (6/18), DIC syndrome - in 8/18 (44,4%) with 1 intracranial hemorrhage.All patients received allopurinole 600 mg/day. PA procedures were started during cytoreductive therapy (hydroxyurea 10 mg/kg/day 1-2 days) sometimes with leukapheresis (LA) and were continued within 1 or 2 days of conventional 7+3 (ARA-C 100 mg/m2 bid iv 1-7 d, DNR 60 mg/m2 x 3d) 2 hours after short (30 min) ARA-C infusion. DNR was applied on days 3 to 5 or 5 to 7, thus PA did not interfere with its pharmacokinetic properties. All patients concomitantly have got intensive hydrating (3-4 l) and diuretic therapy with electrolytes and albumin support.Results: Cytoreductive therapy with hydroxyurea was used for a median 2 days (1-7 dd). Half of the patients (9/18) have got 1-2 procedures of LA (median 2). Median 2 (1-4) procedures of PA were performed in 17/18 patients. The volume of removed plasma for 1 PA procedure was 1200 ml (900-1500 ml), the volume of compensation was – plasma 1100 ml (500-1600 ml) +/- 20% albumin 50-150,0 and 0,9% NaCl 500-1000,0.Median WBC count after cytoreductive therapy at the 1st day of 7+3 was 60x109/l (5,6-124x109/l). DNR was administered on days 5-7 in 16 and on days 3-5 - in 2 patients. No severe cytolysis with the development of multiple organ failure was observed. Only 1 patient with massive extramedullary involvement has developed just laboratory signs of acute renal failure without stopping the urinary function. Less than third of the patients (5/18) developed the transient signs of volemic overload within the first days of chemotherapy treated successfully with diuretics and plasmapheresis.CR after the 1st induction was achieved in 50% of (9/18) patients. Additional 7 patients achieved CR after the 2nd induction, resulting in 89% overall CR rate. Only 1 patient (5,5%) died with severe infectious complications during aplasia. Allogeneic bone marrow transplantation was performed in 8 of 16 CR patients. The median OS and DFS was 28 and 23 months, 3-years OS and DFS was 32% and 35% respectively.Conclusions. Our small study brought us to a conclusion that serial PA procedures during cytoreductive phase and the first days of 7+3 may prevent the development of tumor lysis syndrome and its complications. This clinical approach is feasible, easy to perform and decreases early mortality. DisclosuresNo relevant conflicts of interest to declare.

Plasmapheresis as preconditioning protocol in an extremely high titer ABO incompatible renal transplant (ABOiRTx) case: A new prospect for chronic kidney disease patients in India

The biggest hurdle in renal transplantation is the ABO blood group system. But recently ABO incompatible renal transplants have been performed using plasmapheresis (PP) as a part of the preconditioning protocol. In the present study, the objective of PP along with immunosuppression was to bring down the antibody titer of the patient to ⩽16 during the transplant and keep it low, around 32, until post-operative 4–14weeks. The patient (O Negative) had his mother (B Positive) as the ABO non-identical donor. The PP was performed with an apheresis equipment Com.Tec (Fresenius Kabi, Germany) to lower the anti-B antibody titer in the recipient. An Antihuman globulin (AHG) titer was performed for anti-B antibody following the departmental standard operating procedure. A total of 11 plasmapheresis procedures was performed preoperatively and four procedures were performed post-operatively to maintain the titer of the anti-B antibody at or below the desired level. The baseline anti-B antibody titer in the recipient was 512. The baseline titer came down to 8 after the end of the 11th procedure. Post-operatively we performed four plasmapheresis procedures to keep the titer at 32. During the post-operative follow up the titer has been maintained at 32 and the serum creatinine level has been maintained at approximately 1.0mg/dl and other parameters relevant to graft function were within normal limits. Our case could be the first reported case from India in which we used a plasmapheresis procedure as a part of preconditioning protocol instead of using an immunoadsorption column. Furthermore, it could be one of the few ABOiRTx cases, which has been performed at an isoagglutinin titer of 512 using plasma exchange as part of a preconditioning regime.

Extracorporeal immunoadsorption of antibodies against the VRT-101 laminin epitope in systemic lupus erythematosus: a feasibility evaluation study

We have previously shown that lupus antibodies directed against extracellular membrane components bind to the kidneys and cause damage. The target epitope was a peptide located at the globular part of the α-chain of laminin, designated VRT-101. The titers of anti-VRT-101 antibodies correlated with disease activity and demonstrated pathogenic properties. In the present study, we set out to test the feasibility and safety of treating SLE patients with extracorporeal immunoadsorption on the VRT-101 coupled column, Lupusorb, in an attempt to eliminate these pathogenic antibodies. Ten SLE patients were enrolled and treated with a single session of plasmapheresis combined with serum filtration through Lupusorb. The follow-up period was from recruitment until 8 weeks post-treatment. Monitoring of subjects included documentation of adverse events, anti-VRT-101 levels, SLE inflammatory markers (anti-DNA, CRP, C3, C4, urine protein) and clinical assessment (SLEDAI score). A total of 11 adverse experiences were documented in 7 patients, none of which required withdrawal from the study. Eight adverse experiences were unrelated or unlikely related to treatment. The remaining 3 were classified as possibly treatment related and were attributed to the plasmapheresis procedure. Following Lupusorb treatment, a statistically significant decrease was detected in the serum level of anti-VRT-101 antibodies (38.75% reduction; p = 0.009). Concomitantly, a favorable trend was observed in disease activity markers as well as in the SLEDAI score. Our data indicate that Lupusorb is a safe and effective modality for eliminating anti-VRT-101 antibodies. Additional studies are warranted to confirm its therapeutic potential.

Perioperative Therapeutic Plasmapheresis

Perioperative Therapeutic Plasmapheresis

Development of an automated plasmapheresis procedure for the harvest of equine plasma in accordance with current good manufacturing practice

To develop a high-speed, continuous-flow, automated plasmapheresis procedure for the high-volume harvest of equine plasma in accordance with current good manufacturing practice. 143 horses (predominantly draft breeds) between 3 and 10 years of age at the time of purchase. Adaptations were made to automated plasmapheresis instruments and sterile disposable collection sets, which allowed for dual-instrument, continuous-flow operation. Donor horses were connected to the apparatus via 2 catheters (1 inserted in each jugular vein). The instruments removed whole blood from donors, fractionated the blood, diverted plasma to collection bags, and simultaneously returned concentrated cells to the donors. Plasmapheresis was performed on donor horses at 14-day intervals with a maximum of 22 mL of plasma/kg of donor body weight harvested during each plasmapheresis procedure. During a 5-year period, 3,240 plasmapheresis procedures were performed and > 50,000 L of sterile equine plasma was harvested in accordance with current good manufacturing practice. Donors typically remained calm during the plasmapheresis procedures and tolerated the procedures well. The high-volume and frequent plasma harvest did not result in sustained hypoproteinemia in donor horses. Adverse events associated with the automated plasmapheresis technique were infrequent, and the recurrence of adverse events was minimized by making minor adjustments to the procedure. The automated plasmapheresis procedure described in this report can be used to safely harvest equine plasma or to perform therapeutic plasmapheresis in horses.

Plasmapheresis and Cyclophosphamide therapy in an eight year old girl with cerebral manifestation of systemic lupus erythematodes

An eight year old girl suffering from systemic lupus erythematodes (SLE) presented with fever and developed a slurred and slowed speech, followed by hemiparesis of the right side, tremor of the arms and an instable gait. Diagnosis of SLE was done two years ago during an episode of muscle pain and polyarthralgia. From December 2008 until August 2009 the girl has received corticosteroids, naproxen and methotrexate. The cerebral magnetic resonance imaging (MRI) showed multiple T2-weighted hyperintense lesions in the cerebellum, periventricular on the right hemisphere, putamen bilateral and white matter of the frontal lobe. The blood results revealed a consumption of the complement system with decreased values of C3, C4 and CH50, increases of serum inflammatory factors, high values of antinuclear antibodies and of antibodies against dsDNA. Antibodies against SSA (Ro), SSB (La), u1RNP and SM have also been positive for a long time. Antibodies against phospholipids were not detected. High doses of corticosteroids (30 mg/kg/day methylprednisone) have been applied for three days and were followed by an apparent improvement of the hemiparesis. Speech worsened and an organic psychosyndrome developed with confusion, aggressiveness and a loss of short term memory and orientation. Plasmapheresis therapy on three consecutive days was performed and was followed by a prompt improvement of the organic psychosyndrome. After the second plasmapheresis procedure the girl developed an insult with a seizure. An MRI showed new hyperintense T2 lesions in the occipito-parieto-temporal area and in the frontal lobe in the white matter without restricted diffusion. Most of the known former lesions showed a dramatic improvement. Nine days after plasmapheresis and seven days after the first cyclophosphamide therapy the patient showed an impressive clinical improvement. Four weeks after the first symptoms the hyperintense lesions were in regression and the complement levels were within normal limits. The immunosuppressive therapy consisted of daily corticosteroids and intravenous cyclophosphamide in four weekly intervals and a continuous anticoagulation has been applied. Now ten months after the severe cerebral manifestation of SLE, the girl is well and going to school without any neurological handicap.