Abstract:The principles and use of plasmapheresis are often little understood by intensivists. We propose to review the principles, the main indications, and the methods of using this technique.
“…Plasma exchange or plasma filtration [ 14 ] are techniques that enable the removal of most molecules present in plasma, spanning in size from any small solute to large protein such as globulins [ 15 ]. These techniques remove a broad array of molecules that are believed to be toxic as in sepsis [ 16 ] or severe liver failure [ 17 ]. However, removal is non-selective and simultaneous removal of a large array of potentially beneficial or necessary molecules (clotting factors, albumin, antibiotics, and protective antibodies) takes place.…”
Section: The Logic Behind Hemoperfusionmentioning
confidence: 99%
“…Plasmafiltration-adsorption combined with dialysis/CRRT : PFAD or CPFA can be combined with hemodialysis (PFAD-HD) or CRRT (CPFA-CRRT) to expand the efficiency of the treatment to small solutes such as urea and creatinine (Fig. 4 ) [ 16 ]. Fig.…”
Section: Technical Aspects Of Hemoperfusionmentioning
Background
Blood purification through the removal of plasma solutes by adsorption to beads of charcoal or resins contained in a cartridge (hemoperfusion) has a long and imperfect history. Developments in production and coating technology, however, have recently increased the biocompatibility of sorbents and have spurred renewed interest in hemoperfusion.
Methods
We performed a narrative assessment of the literature with focus on the technology, characteristics, and principles of hemoperfusion. We assessed publications in ex vivo, animal, and human studies. We synthesized such literature in a technical and state-of-the-art summary.
Results
Early hemoperfusion studies were hampered by bioincompatibility. Recent technology, however, has improved its safety. Hemoperfusion has been used with positive effects in chronic dialysis and chronic liver disease. It has also demonstrated extraction of a variety of toxins and drugs during episodes of overdose. Trials with endotoxin binding polymyxin B have shown mixed results in septic shock and are under active investigation. The role of non-selective hemoperfusion in sepsis or inflammation remains. Although new technologies have made sorbents more biocompatible, the research agenda in the field remains vast.
Conclusion
New sorbents markedly differ from those used in the past because of greater biocompatibility and safety. Initial studies of novel sorbent-based hemoperfusion show some promise in specific chronic conditions and some acute states. Systematic studies of novel sorbent-based hemoperfusion are now both necessary and justified.
“…Plasma exchange or plasma filtration [ 14 ] are techniques that enable the removal of most molecules present in plasma, spanning in size from any small solute to large protein such as globulins [ 15 ]. These techniques remove a broad array of molecules that are believed to be toxic as in sepsis [ 16 ] or severe liver failure [ 17 ]. However, removal is non-selective and simultaneous removal of a large array of potentially beneficial or necessary molecules (clotting factors, albumin, antibiotics, and protective antibodies) takes place.…”
Section: The Logic Behind Hemoperfusionmentioning
confidence: 99%
“…Plasmafiltration-adsorption combined with dialysis/CRRT : PFAD or CPFA can be combined with hemodialysis (PFAD-HD) or CRRT (CPFA-CRRT) to expand the efficiency of the treatment to small solutes such as urea and creatinine (Fig. 4 ) [ 16 ]. Fig.…”
Section: Technical Aspects Of Hemoperfusionmentioning
Background
Blood purification through the removal of plasma solutes by adsorption to beads of charcoal or resins contained in a cartridge (hemoperfusion) has a long and imperfect history. Developments in production and coating technology, however, have recently increased the biocompatibility of sorbents and have spurred renewed interest in hemoperfusion.
Methods
We performed a narrative assessment of the literature with focus on the technology, characteristics, and principles of hemoperfusion. We assessed publications in ex vivo, animal, and human studies. We synthesized such literature in a technical and state-of-the-art summary.
Results
Early hemoperfusion studies were hampered by bioincompatibility. Recent technology, however, has improved its safety. Hemoperfusion has been used with positive effects in chronic dialysis and chronic liver disease. It has also demonstrated extraction of a variety of toxins and drugs during episodes of overdose. Trials with endotoxin binding polymyxin B have shown mixed results in septic shock and are under active investigation. The role of non-selective hemoperfusion in sepsis or inflammation remains. Although new technologies have made sorbents more biocompatible, the research agenda in the field remains vast.
Conclusion
New sorbents markedly differ from those used in the past because of greater biocompatibility and safety. Initial studies of novel sorbent-based hemoperfusion show some promise in specific chronic conditions and some acute states. Systematic studies of novel sorbent-based hemoperfusion are now both necessary and justified.
“…Membrane therapeutic plasma exchange (mTPE) is an extracorporeal blood purification technique that enables the unselective removal of blood solutes almost up to the size of cellular components. 1 , 2 The physical mechanism that enables mTPE is convection, in which pressure is applied to a semipermeable membrane, this causes fluid movement across the membrane and drag forces removing large molecules. 3 The indications for mTPE are mainly related to antibody-mediated diseases, in which the mechanical removal of antibodies mitigates briefly the disease process.…”
Section: Introductionmentioning
confidence: 99%
“… 1 An alternative to mTPE is centrifugal therapeutic plasma exchange (cTPE), in which the blood is diverted to a rotating chamber, and the separation of blood elements depends on the differences in density of each component. 2 One advantage of cTPE is that it can be performed with lower blood flows when compared to mTPE, 50-70 mL/min versus 120-150 mL/min, respectively. This allows cTPE to be carried out using a peripheral venous access, whereas mTPE requires a hemodialysis vascular access.…”
Section: Introductionmentioning
confidence: 99%
“…This allows cTPE to be carried out using a peripheral venous access, whereas mTPE requires a hemodialysis vascular access. However, cTPE requires a dedicated machine while mTPE uses commonly available CRRT machines; 2 therefore, the use of mTPE is becoming more common. We present a series of 2 cases in which we performed a total of 12 sessions of mTPE using RCA.…”
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.
Background
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.
Objective
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.
Methods
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).
Results
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).
Conclusion
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.
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