Assessment of Hemostasis after Plasma Exchange Using Rotational Thrombelastometry (ROTEM)

Abstract

BackgroundTherapeutic plasma exchange (TPE)-based protocols immediately before cadaveric donor kidney transplantation have been extensively used in highly sensitized recipients. Plasma is generally preferred over human albumin as replacement fluid to avoid depletion of coagulation factors and perioperative bleeding. The aim of this study was to estimate bleeding risk after TPE replaced with albumin using rotational thromboelastography (ROTEM).MethodologyTen patients without overt coagulation abnormalities underwent TPE. Standard laboratory coagulation tests (thromboplastin time, activated partial thromboplastin time (aPTT), international normalized ratio (INR), thrombin clotting time, fibrinogen levels and antithrombin activity) were compared with thrombelastometry analysis (EXTEM and INTEM tests) before and after TPE.Principal FindingsTPE significantly reduced fibrinogen levels (482 ± 182 vs. 223 ± 122 mg/dL), antithrombin activity (103 ± 11 vs. 54 ± 11 %), and prolonged aPTT (28 ± 3 vs. 45 ± 8 s), thromboplastin time (108 ± 11 vs. 68 ± 11 %), INR (0.95 ± 0.06 vs. 1.25 ± 0.16), and thrombin clotting time (18 ± 2 vs. 20 ± 3 s). INTEM and EXTEM analyses revealed significantly prolonged clot-formation time and reduced maximum clot firmness.Conclusions/SignificanceTPE replaced with albumin induces significant changes in global hemostasis parameters thus potentially increasing bleeding risk. Therefore, pretransplant TPE should be considered carefully in indicated patients before kidney transplantation. The role of the ROTEM point-of-care test to estimate the risk of bleeding in renal transplantation needs to be evaluated in further studies.

Effects of therapeutic plasma exchange on anticoagulants in patients receiving therapeutic anticoagulation: a systematic review

“…For patients receiving albumin replacement, TPE alone, without the added impact of anticoagulant therapy, has been shown to have an effect on both coagulation proteins, including aPTT and INR levels (see Table ) . In a prospective study of 10 patients who underwent albumin TPE, TPE prolonged aPTT (28 ± 3 vs. 45 ± 8 sec) and INR (0.95 ± 0.06 vs. 1.25 ± 0.16) . Another study of 35 patients showed aPTT increase from 41.6 to 49.3 seconds and INR increase from 1.28 to 1.74 .…”

“…In therapeutic plasma exchange (TPE), the process of plasma removal and replacement affects blood coagulation proteins . TPE‐mediated coagulation protein removal and its effects on fibrin clot formation alter the hemostatic profile . The coagulation profile is further modified by TPE‐related factors such as procedure frequency and duration, procedural plasma volume, and replacement fluid .…”

Point-of-care diagnostics for niche applications

“…This includes activated clotting time (Bittl, 2005), thrombelastography, rotational thromboelastometry (Mallett and Cox, 1992, Saner, 2014, Thölking et al, 2015), and platelet function (Agarwal et al, 2015, Petricevic et al, 2015). Many of the in vitro diagnostic tests attempt to extract information on certain pathways of the clotting cascade, primarily extrinsic and intrinsic pathways.…”

Hemostasis testing and therapeutic plasma exchange: Results of a practice survey

“…In addition, five centers reported using membrane filtration and were excluded from analysis and 15 respondents dropped out of the survey prior to this question so their method of plasma separation is unknown. Furthermore, we did not inquire about other tests of hemostasis such as thromboelastography (TEG) and rotational elastometry (ROTEM) . However, based on the authors' experiences, the use of TEG and ROTEM was considered not to be a test routinely utilized during TPE treatment and therefore was not queried.…”

“…Less is known about how to monitor TPE associated coagulopathy and the risk of bleeding, especially when there is ongoing anticoagulation and antiplatelet therapy . A number of tests have been shown to be reflective of this coagulopathy, including fibrinogen levels, prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT), and more recently, rotational thromboelastometry (ROTEM) . Furthermore, there are currently no defined guidelines regarding the frequency of testing, type of tests to perform, and actionable thresholds for patients undergoing TPE treatment.…”