Fibrinogen Reduction and Bleeding Complications in Plasma Exchange, Immunoadsorption and a Combination of the Two

Abstract

Background: Immunoadsorption (IAS) and therapeutic plasma exchange (TPE) are considered safe although fibrinogen is removed. To date no comparison of fibrinogen reduction and associated risk of bleeding in apheresis exists. Methods: Retrospective analysis of TPE, three IAS adsorbers, and combined TPE/IAS regarding fibrinogen reduction and bleeding incidence in 67 patients (1,032 treatments). Results: TPE and TPE/IAS reduced fibrinogen by 64 ± 11% and 58 ± 9%, leading to concentrations <100 mg/dl in 20 and 17% of treatments, respectively. IAS decreased fibrinogen less than TPE (26 ± 6%, p < 0.0001), resulting in fibrinogen concentrations <100 mg/dl in 1% of treatments. The processed volume correlated with reduction in TPE (r = 0.64, p < 0.01), but not in IAS. Bleeding occurred in 1.3% (IAS), 2.3% (TPE) and 3.1% (TPE/IAS) of treatments. Conclusion: Hypofibrinogenemia occurs in 20% of patients after TPE and TPE/IAS, but rarely after IAS. IAS removes fibrinogen independently of volume processed. Overall, bleeding is rare in apheresis.

Selective Plasma Exchange for the Removal of Pemphigus Autoantibodies, Fibrinogen, and Factor XIII in Pemphigus Vulgaris

“…Only direct measurement of FXIII itself is needed for the diagnosis of FXIII deficiency . Decreased fibrinogen at a level of <100 mg/dL can contribute to hemorrhage and the necessity of additional treatment to restore normal hemostasis . In the previous and present studies, the percent reduction of fibrinogen after one session of plasma exchange with Alb supplementation, DFPP, IA, and SePE was 63.2%, approximately 50%–60%, 67.7%, and 17.6%, respectively, and that of FXIII was approximately 63%, 53%, approximately 30%, and 9.3%–16%, respectively .…”

A prospective study comparing tryptophan immunoadsorption with therapeutic plasma exchange for the treatment of chronic inflammatory demyelinating polyneuropathy*

“…Fibrinogen reduction was more pronounced in the PE group, but no bleeding complication occurred. It has been shown recently that after PE coagulation factors were significantly reduced by 50–70%, whereas after IA, a distinct reduction was observed for fibrinogen, but not for antithrombin and most of the other coagulation factors …”

“…It has been shown recently that after PE coagulation factors were significantly reduced by 50-70%, whereas after IA, a distinct reduction was observed for fibrinogen, but not for antithrombin and most of the other coagulation factors. 13,18 In terms of mildly adverse events, there was one event of limb numbness in the IA and one event of slight dizziness in the PE group. As IA does not necessitate the substitution with human plasma products, there is a presumed better tolerability by reducing the risk of allergic reactions.…”

Fibrinogen Reduction During Selective Plasma Exchange due to Membrane Fouling

“…In one study, after five sessions of DFPP, fibrinogen concentration was reduced to <70 mg/dL in 44% of patients . Fibrinogen concentration of <100 mg/dL can potentially contribute to hemorrhaging and the need for additional treatment to restore normal hemostasis . The retention of fibrinogen can be important in plasmapheresis treatment.…”