Therapeutic Apheresis in Children: Experience in a Pediatric Dialysis Center

Abstract

The use of apheretic procedures in pediatric patients has always been restricted by technical difficulties and the low incidence of diseases requiring this kind of treatment. The aim of the present study was to describe the solutions adopted to solve technical difficulties related to priming, vascular access and monitoring and then to evaluate clinical results. Between 1982 and 2000, 51 consecutive children (28 male, 23 female) with a mean age of 4.9 ± 4.8 years (3 months – 14.8 years) and a mean weight of 19.7 ± 12.8 kg (5 – 52 kg), with renal and/or extra-renal diseases requiring apheretic procedures were selected for the study. The overall number of procedures performed were: 226 plasma-exchange (PE), 6 LDL-apheresis (LDL-A) and 8 protein A immunoadsorption (IAPA) sessions. Our therapeutic protocol involves hematic flux of 20 – 100 ml/min and ultrafiltration of 5–20 ml/min. In each 70–95 minute session we exchanged plasmatic volume with fresh frozen plasma or with a solution of 6% albumin in lactated Ringer's, using heparin (10–20 UI/kg/h). We used Paired Filtration Dialysis Monitor in PE and LDL-A; Citem 10 in IAPA. As plasma separator, we used a filter made of polypropylene, 0.2 m2 surface, 30 ml priming (Hemaplex BT 900). Hemolytic uremic syndrome was the most commonly treated disease (18/51 cases) with good results in 10/18 cases. We recorded, good results in vasculitis as well, in one girl with focal glomerulosclerosis in transplanted kidney and rapid improvement in all children with Guillaine-Barré Syndrome. PE treatment was effective in metabolic disorders such as tirosynemia and familiar hypercolesterolemia. Only 4/12 patients with acute liver failure due to viral hepatitis recovered. We had poor results in the remaining eight cases. Complications were rare and no viral infection was found in any patient. Our data show that it is possible to use these procedures in pediatric patients even though clinical indications and real effectiveness still need to be cleared up.

Plasma Exchange Using a Continuous Venovenous Hemofiltration Machine in Children

“…Comparing our study with De Palo et al's [4] report, we found that the blood fl ow and turnover rates resembled our own fi ndings. Our maximum blood fl ow rate (109 8 63 ml/min) slightly exceeded their recommendation of 20-100 ml/min.…”

“…Our maximum turnover rate (0.72 8 0.32 l/h) approximated their recommendation of 0.3-1.2 l/h. The major indication for PE was diarrhea-associated HUS in De Palo et al's [4] series. In our series, the most common indication for PE was medication-resistant FSGS.…”

“…It is thought that this increased demand is the result of heparin being removed during the PE process [16] . It is surprising that in De Palo's series [4] , only 10-20 units/kg/h were recommended. No details on ACT were provided.…”

“…However, these papers did not base their suggestions on a critical review of their practices. Only two reports describe the technical aspects in detail [4,5] while providing a critical review of their practices. De Palo et al [4] described the use of standard and adaptive machinery techniques with paired fi ltration dialysis monitors for PE over a 20-year period.…”

“…Only two reports describe the technical aspects in detail [4,5] while providing a critical review of their practices. De Palo et al [4] described the use of standard and adaptive machinery techniques with paired fi ltration dialysis monitors for PE over a 20-year period. Ponikvar et al [5] described the use of a CVVH machine in only 3 patients for the same purpose.…”