Role Of Therapeutic Plasma Exchange Research Articles

The role of therapeutic plasma exchange using membrane plasma separation in the late onset myasthenic crisis: a case report

Myasthenia gravis (MG) is an autoimmune disease, in which antibodies bind to receptors in the neuromuscular junction (NMJ), causing muscle weakness. This disease is relatively challenging to diagnose due to its late onset and comorbidities. Several treatment options include therapeutic plasma exchange (TPE) with membrane plasma separation, that aims to remove large molecular-weight toxins such as pathogenic antibodies and lipoproteins. A 61-year-old male patient was admitted to the ICU post-sternotomy due to mediastinal tumor resection. Extubation failed, so we decided to undergo a tracheostomy. The lung pathology result showed lymphocyte-predominant thymoma, and along with symptoms of chest weakness and ptosis, the patient was suspected for MG. Electromyography results confirmed the occurrence of functional lesions in post-synaptic NMJ consistent with MG. We assessed patient with myasthenic crisis (MC), then gave pyridostigmine 60 mg 6x/day, and planned for TPE using membrane plasma separation. Plasma exchange was done by 1.5 of blood volume. The patient developed sepsis pneumonia and was administered levofloxacin based on his culture results. Patient still had weakness. We re-evaluated the drugs that might have exacerbated MG. Aztreonam in combination with co-trimoxazole was administered to combat Stenotrophomonas maltophilia pneumonia. The patient was eventually weaned from the ventilator and gradually recovered. Keywords: Membrane Plasma Separation; Myasthenia Gravis Crisis; Therapeutic Plasma Exchange; TPE Citation: Kurnia D, Manggala SK, Irawany V. The role of therapeutic plasma exchange using membrane plasma separation in the late onset myasthenia gravis crisis: a case report. Anaesth. pain intensive care 2024;28(5):969−973; DOI: 10.35975/apic.v28i5.2557 Received: July 17, 2024; Reviewed: August 01, 2024; Accepted: August 01, 2024

Role of therapeutic plasma exchange in dengue-related microangiopathy

Abstract: Thrombotic microangiopathies (TMAs) are a group of disorders characterized by microangiopathic hemolytic anemia and thrombocytopenia, leading to ischemic tissue injury. We, hereby, describe an interesting case of TMA secondary to dengue along with dengue encephalitis. Dengue-related TMA is rarely described. Treatment was initiated with standard-volume (1.5 plasma volume) therapeutic plasma exchange (TPE) by centrifugation method on a multifunctional cell separator (Spectra Optia, Terumo BCT, USA) within a few hours of admission based on high PLASMIC score, which led to improvement in hemolytic parameters and kidney injury. This case highlights the role of early diagnosis and early initiation of TPE is key in the management of dengue-related TMAs.

Role of therapeutic plasma exchange in treatment of the hypertriglyceridemia-induced acute pancreatitis: Case report and literature review

Abstract: Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is associated with a more severe clinical course than acute pancreatitis due to other etiologies. Presently, these patients are managed with dietary restrictions, analgesia, lipid-lowering agents, insulin/heparin dual therapy, and supportive care to prevent organ failure. Apart from these conventional therapies, therapeutic plasma exchange (TPE) is another potential treatment that is being performed as it results in rapid reduction in serum triglycerides and inflammatory cytokines, thus, leading to drastic improvements in clinical and laboratory findings and patient outcomes. Here, we report our experience of using TPE for HTG-AP in our patients.

The role of therapeutic plasma exchange in plasma cell disorders.

Therapeutic plasma exchange (TPE) is an extracorporeal technique where patient's plasma containing pathogenic substances is separated and removed from the whole blood, while the cellular component is returned to the patient mixed with replacement solution via an apheresis machine. Due to its ability to remove pathogenic substances from plasma including immunoglobulins, TPE has proven efficacious in the management of various disorders across different medical disciplines, including plasma cell dyscrasias, which are characterized by the abundant secretion of non-functional immunoglobulins produced by an abnormally proliferating plasma cell clone. This review summarizes the current indications of TPE in plasma cell-related disorders and discusses its application, safety, and therapeutic effects.

A case of acquired thrombotic microangiopathy secondary to Russell’s viper bite

Russell’s viper is one of the ‘big four’ most dangerous poisonous snakes in India. The farmer and snakes, especially the Russell's viper, coexist in tenuous relationship in the ecosystem. The clinical manifestations of viper bite are localized pain and swelling, coagulopathy, and renal impairment. The venom induced consumption coagulopathy (VICC) following Russell’s viper bite can result in a syndrome consistent with thrombotic microangiopathy (TMA), manifesting with thrombocytopenia, microangiopathic hemolytic anemia (MAHA) and acute kidney injury (AKI). TMA is rarely reported as a complication of Russell’s viper envenoming. Our patient, a farmer, was bitten by Russell’s viper and was brought to a nearby hospital within an hour. He was administered anti-snake venom (ASV) and supportive therapy. As his renal function declined, he was transferred to our hospital. He developed thrombocytopenia, and MAHA as evidenced by progressive anemia, schistocytes on peripheral smear, increased levels of lactate dehydrogenase (LDH), and AKI unresponsive to fluid management and diuretic administration. He was managed with sustained low-efficiency dialysis (SLED) and therapeutic plasma exchange (TPE). After three cycles of TPE and seven cycles of SLED over the next three weeks, the patient recovered completely and has been asymptomatic for more than six-months during follow up. The case is reported for rarity of TMA in the Russell’s viper envenomation, and the role of TPE in such cases.

P‐TA‐10 | Role of Therapeutic Plasma Exchange in Immune Checkpoint Inhibitor Therapy‐Induced Adverse Events

P‐TA‐10 | Role of Therapeutic Plasma Exchange in Immune Checkpoint Inhibitor Therapy‐Induced Adverse Events

Outcomes of therapeutic plasma exchange in severe autoimmune hemolytic anemia hospitalizations: An analysis of the National Inpatient Sample.

Autoimmune hemolytic anemia (AIHA) is characterized by humoral and/or cellular immune-mediated hemolysis of red blood cells. The role of therapeutic plasma exchange (TPE) in AIHA is unclear. We queried the National Inpatient Sample (NIS) for 2002-2019 to identify hospitalizations with the primary diagnosis of AIHA. We included hospitalizations with the highest severity subclass identified by All Patient Refined Disease Related Group (APR-DRG). We used multivariate regression analysis to compare in-hospital mortality and other relevant in-hospital outcomes between hospitalizations that received TPE and those that did not. We identified 255 weighted hospitalizations in the TPE group and 4973 in the control group. Those in the control group were older (median age 67 vs. 48 years, p < .001) and had a higher prevalence of most comorbidities. The TPE group had higher odds of all-cause in-hospital mortality (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.19-2.11). They also had higher rates of many secondary outcomes, including requiring mechanical ventilation, developing circulatory shock, acute stroke, urinary tract infections, intracranial hemorrhage, acute kidney injury, and requiring new hemodialysis. No significant differences were noted in the rates of acute myocardial infarctions, bacterial pneumonia, sepsis/septicemia, thromboembolic events, and other bleeding events. Furthermore, the TPE group had a higher median length of hospital stay (19 vs. 9 days, p < .001). Hospitalizations with severe AIHA that received TPE had higher rates of adverse in-hospital outcomes.

Renal replacement and extracorporeal therapies in critical care: current and future directions

There are a wide number of indications for extracorporeal therapies in the critical care environment. A common indication seen by the acute physician is continuous renal replacement therapy (CRRT) in a proportion of patients with acute kidney injury. It is therefore important that acute physicians have a sound understanding of the principles of CRRT in the acutely unwell patient. This review will outline the indications for its use, commonly used methods and anticoagulation considerations. It will discuss when to start and stop CRRT as well as describing potential treatment complications. This review will also discuss the role of therapeutic plasma exchange in critical care and novel extracorporeal therapies including blood purification in sepsis and carbon dioxide removal in acute respiratory distress syndrome and acute exacerbations of obstructive lung disease. Extracorporeal membrane oxygenation is outside of the scope of this article.

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.

Drug-induced thrombotic microangiopathy: An updated review of causative drugs, pathophysiology, and management.

Drug-induced thrombotic microangiopathy (DITMA) represents 10%-13% of all thrombotic microangiopathy (TMA) cases and about 20%-30% of secondary TMAs, just behind pregnancy-related and infection-related forms. Although the list of drugs potentially involved as causative for TMA are rapidly increasing, the scientific literature on DITMA is quite scarce (mostly as individual case reports or little case series), leading to poor knowledge of pathophysiological mechanisms and clinical management. In this review, we focused on these critical aspects regarding DITMA. We provided an updated list of TMA-associated drugs that we selected from a scientific literature review, including only those drugs with a definite or probable causal association with TMA. The list of drugs is heterogeneous and could help physicians from several different areas to be familiar with DITMA. We describe the clinical features of DITMA, presenting the full spectrum of clinical manifestations, from systemic to kidney-limited forms. We also analyze the association between signs/symptoms (i.e., malignant hypertension, thrombocytopenia) and specific DITMA causative drugs (i.e., interferon, ticlopidine). We highlighted their multiple different pathophysiological mechanisms, being frequently classified as immune-mediated (idiosyncratic) and dose-related/toxic. In particular, to clarify the role of the complement system and genetic deregulation of the related genes, we conducted a revision of the scientific literature searching for DITMA cases who underwent renal biopsy and/or genetic analysis for complement genes. We identified a complement deposition in renal biopsies in half of the patients (37/66; 57%), with some drugs associated with major deposits (i.e., gemcitabine and ramucirumab), particularly in capillary vessels (24/27; 88%), and other with absent deposits (tyrosine kinase inhibitors and intraocular anti-VEGF). We also found out that, differently from other secondary TMAs (such as pregnancy-related-TMA and malignant hypertension TMA), complement genetic pathological mutations are rarely involved in DITMA (2/122, 1.6%). These data suggest a variable non-genetic complement hyperactivation in DITMA, which probably depends on the causative drug involved. Finally, based on recent literature data, we proposed a treatment approach for DITMA, highlighting the importance of drug withdrawal and the role of therapeutic plasma-exchange (TPE), rituximab, and anti-complementary therapy.

Role of therapeutic plasma exchange as a desensitization therapy in human leukocyte antigen incompatible renal transplant patients: A single-center experience

ObjectiveDespite an increase in the rate of successful live donor renal transplantation done annually, the number of potential recipients with acceptable donors is relegated to the ever-expanding cadaver-donor waiting list due to sensitization to human leukocyte antigen (HLA) antibodies. If not sufficiently suppressed, these preformed HLA antibodies can trigger antimicrobial resistance (AMR) and early graft loss. To ameliorate this situation, various desensitization treatments are administered to provide a survival benefit to highly sensitized patients. MethodOne hundred and six patients in the time frame of January 2017 to March 2019 were included in the study group. The desensitization protocol included therapeutic plasma exchange and administration of low-dose intravenous immunoglobulin (100 mg/kg per therapeutic plasma exchange (TPE) session) to highly sensitized patients (treatment group) who subsequently underwent renal transplantation after negative pre-transplant Centers for Disease Control and Prevention Luminex crossmatch (CDC/LumXM). We compared graft survival rates between the group undergoing desensitization (treatment group) and matched control group of patients that underwent HLA-compatible transplantation. ResultsIn the treatment group, Kaplan-Meier analysis estimates an average rate of patient graft survival of 95.2% at 3 years post-transplant, as compared with the rate of 86.9% in the same time frame for the control-matched group (p < 0.05 for both comparisons). ConclusionDesensitization treatment with TPE before live donor renal transplantation in the case of patients with HLA sensitization provides better survival benefits along with monitoring for donor-specific antibodies (DSAs) and other infections, rather than waiting for a compatible organ donor. The data lays out evidence that desensitization treatments can assist overcome HLA incompatibility barriers in live donor renal transplantation.

Therapeutic plasma-exchange improves short-term, but not long-term, outcomes in patients with acute-on-chronic liver failure: A propensity score-matched analysis.

Acute-on-chronic liver failure (ACLF) is associated with a high short-term mortality rate in the absence of liver transplantation. The role of therapeutic plasma exchange (TPE) in improving the outcomes of ACLF and acute decompensation (AD) is unclear. In this retrospective analysis, we aimed to determine the impact of TPE on mortality in patients with ACLF. ACLF patients receiving TPE with standard medical treatment (SMT) were propensity score matched (PSM) with those receiving SMT alone (1:1) for sex, grades of ACLF, CLIF C ACLF scores, and the presence of hepatic encephalopathy. The primary outcomes assessed were mortality at 30 and 90 days. Survival analysis was performed using Kaplan Meier survival curves. A total of 1151 patients (ACLF n=864 [75%], AD [without organ failure] n=287 [25%]) were included. Of the patients with ACLF (n=864), grade 1, 2, and 3 ACLF was present in 167 (19.3%), 325 (37.6%), and 372 (43.0%) patients, respectively. Thirty-nine patients received TPE and SMT, and 1112 patients received only SMT. On PSM analysis, there were 38 patients in each group (SMT plus TPE vs SMT alone). In the matched cohort, the 30-days mortality was lower in the TPE arm compared to SMT (21% vs 50%, P=.008), however, the 90-day mortality was not significantly different between the two groups (36.8% vs 52.6%, P=.166); HR, 0.82 (0.44-1.52), P=.549. TPE improves short-term survival in patients with ACLF, but has no significant impact on long-term outcomes. Randomized control trials are needed to obtain a robust conclusion in this regard.

Plasma exchange and COVID 19

Plasma exchange and COVID 19

Cardiovascular Outcomes in Children with Multisystem Inflammatory Syndrome Treated with Therapeutic Plasma Exchange.

Multisystem inflammatory syndrome in children is a new, rare, post-infectious complication of SARS-CoV-2 infection in children. The aim of this study was to display the role of therapeutic plasma exchange on cardiovascular outcomes in children with multisystem inflammatory syndrome. This study included children who met the diagnostic criteria for multisystem inflammatory syndrome and who were admitted to the intensive care unit. This is a prospective single-center study conducted between August 2020 and September 2021. Subjects had cardiac involvement which was defined as elevated troponin I, abnormal electrocardiographic and echocardiographic findings. Patients were followed by a pediatric cardiologist throughout the intensive care unit stay and after discharge for 12 months. Patients were divided into two groups which received therapeutic plasma exchange and which did not. 38 children were included in this study. There were 16 patients in the no plasma exchange group and 22 patients in the plasma exchange group. The two groups were similar in age, sex, leucocyte, thrombocyte count, neutrophil percentage, hemoglobin, C-reactive protein, erythrocyte sedimentation rate, alanine aminotransferase, albumin, ferritin, fibrinogen, D-dimer, IL-6, troponin I, number of electrocardiographic abnormalities and patients with mitral valve regurgitation detected at admission (p &gt; 0.05). There was no significant difference between the two groups in terms of duration of normalization of electrocardiographic abnormalities and disappearance of mitral valve regurgitation (p &gt; 0.05). Duration of normalization of troponin I (2, IQR 1-4, versus 5, IQR 3-9 days; p = 0.044) and length of hospital stay (7, IQR 6-10, versus 13, 8-20 days; p = 0.001) was longer in the plasma exchange group. We did not observe any significant improvement in children having undergone plasma exchange as compared to children who did not. On the opposite, their length of hospital stay and time to troponin I normalisation were even longer. Some baseline differences in cardiac attainment severity may partly explain this finding.

FERRITIN-GUIDED THERAPEUTIC PLASMA EXCHANGE (TPE) ADMINISTRATION IN COVID-19-INDUCED CYTOKINE STORM SYNDROME: A CASE SERIES

FERRITIN-GUIDED THERAPEUTIC PLASMA EXCHANGE (TPE) ADMINISTRATION IN COVID-19-INDUCED CYTOKINE STORM SYNDROME: A CASE SERIES

SMALL VESSELS, BIG PROBLEMS: MICROSCOPIC POLYANGIITIS PRESENTING AS DIFFUSE ALVEOLAR HEMORRHAGE

SMALL VESSELS, BIG PROBLEMS: MICROSCOPIC POLYANGIITIS PRESENTING AS DIFFUSE ALVEOLAR HEMORRHAGE

Role of Therapeutic Plasma Exchange in Neuromyelitis Optica

Neuromyelitis optica (NMO) is an inflammatory demyelinating disease of the optic nerves and spinal cord and generally has a relapsing course. It is an autoimmune demyelinating disorder of the central nervous system caused by the binding of aquaporin-4 immunoglobulin G to water channel protein at the astrocyte foot process. Here, we are presenting the effectiveness of therapeutic plasma exchange (TPE) therapy in the improvement of disability scores of 11 patients with NMO. A total of 49 procedures were done, and the mean number of TPE sessions was 4.45. The outcome was analyzed in the form of improvement in the Expanded Disability Status Scale score and visual acuity.

Therapeutic Plasma Exchange in Pediatric Patients With Sinusoidal Obstruction Syndrome/Veno-Occlusive Disease After Hematopoietic Stem Cell Transplantation: A Single-Center Experience.

Sinusoidal obstruction syndrome/venoocclusive disease is a significant complication of hematopoietic stem cell transplantation. Due to high mortality rates, new treatment strategies have been investigated. Here, we have presented outcomes of therapeutic plasma exchange performed on patients with sinusoidal obstruction syndrome/veno-occlusive disease. Our study included 70 pediatric patients diagnosed with sinusoidal obstruction syndrome/veno-occlusive disease. Therapeutic plasma exchange procedures in patients were evaluated retrospectively. There were 9 mild (12.9%), 9 moderate (12.9%), 21 severe (30%), and 31 very severe (44.2%) cases of sinusoidal obstruction syndrome/venoocclusive disease. Therapeutic plasma exchange was performed in 31 of the 70 study patients (59.6%). Moreover, 10/21 patients with severe (47.6%) and 21/31 patients with very severe (67.7%) disease underwent plasma exchange. Mean time from diagnosis of sinusoidal obstruction syndrome/venoocclusive disease to therapeutic plasma exchange initiation was 2.3 days. The 31 patients who received therapeutic plasma exchange had a total of 146 sessions. Overall survival rates at 100 days were 87.1% and 92.3% for patients who did and did not undergo therapeutic plasma exchange, respectively. When patients with mild and moderate disease who were not expected to undergo plasma exchange were excluded (n = 52), 100-day overall survival rates were 87.1% and 90.5% for those who did and did not undergo plasma exchange, respectively. When we compared severe versus very severe groups, no significant difference was found. Plasmapheresis had no positive effect on survival. However, overall survival in all groups was higher than that in the literature, despite the high number of patients with severe and very severe disease. Interpretation of the results is limited by the retrospective nature of the study. Thus, prospective, randomized controlled trials with larger numbers of patients are necessary to investigate the role of therapeutic plasma exchange in patients with sinusoidal obstruction syndrome/veno-occlusive disease.

Role of Therapeutic Plasma Exchange in managing complement mediated thrombotic microangiopathy -Case series.

Role of Therapeutic Plasma Exchange in managing complement mediated thrombotic microangiopathy -Case series.

Therapeutic Plasma Exchange: For Cancer Patients.

Therapeutic plasma exchange is used as a trial method for the treatment of cancer patients. Therapeutic plasma exchange uses in vitro technology to remove pathogenic factors in the plasma, returning the replacement and remaining components to the patient to facilitate cure. In the effort to explore new methods of cancer treatment, the introduction of therapeutic plasma exchange brings new hope for cancer treatment; however, the current evidence supporting therapeutic plasma exchange is controversial, and most of the evidence comes from observational studies, lacking large prospective randomized trials. Therefore, this review attempts to focus on the main indications of therapeutic plasma exchange for the treatment of tumors and their complications, including hematological tumors (multiple myeloma cast nephropathy and hyperviscosity syndrome), nervous system tumors (myasthenia gravis associated with thymoma, paraneoplastic neurological syndrome, Lambert–Eaton myasthenia syndrome, and anti-N-methyl-D-aspartate receptor encephalitis), overdose of chemotherapy drugs. In addition, the issues of side-effects and safety in the use of therapeutic plasma exchange are also discussed. However, well-designed prospective trials are needed to better define the role of therapeutic plasma exchange in cancer.