Bugra OZKAN, Hava Uskudar TEKE, Döndü ÜSKÜDAR CANSU, Garip SAHİN

Therapeutic Plasma Exchange Indications, Complications and Responses : A Single Center, Retrospective Analysis.

Therapeutic plasma exchange (TPE) is a process that allows high molecular weight substances to be removed from plasma. Therapeutic plasma exchange is widely used in many diseases in the practice of internal medicine. Current guidelines on this process have been published in recent years due to increased awareness and accessibility. The most common and most comprehensive of these is the American Apheresis Society (ASFA) guideline. In this study, we retrospectively determined the demographic data, underlying diseases, biochemical parameters, volume and type of replacement fluid, complications developed during and after the procedure, additional treatments, need for dialysis, and the number of sessions for patients who underwent therapeutic plasma exchange for any reason in the internal medicine clinic aimed to reveal aspects that can be improved in clinical practice. In the study, 117 patients between 2007 and 2016 were evaluated retrospectively. Of all cases, 63 (53.8%) were female. At the time of diagnosis, the mean age of the patients was 52.15 ± 16.8 (20-88) years. The most common indications for TPE were thrombotic thrombocytopenic purpura (TTP) and ANCA-associated vasculitis. Fresh frozen plasma and albumin were the most commonly used replacement fluids. Catheter related complication rate was 5.1%. The rate of complication related to TPE during TPE was 19.6%. No fatal reactions to TPE treatment were observed. There was a significant relationship between alkaline phosphatase (ALP) and mortality when the relationship between the laboratory data and the mortality rate of the patients with TTP was considered (p = 0.002). There was a significant correlation between chlorine and hematocrit and mortality in ANCA-associated vasculitis patients (p = 0.029 and p= 0.037, respectively). For the purpose of estimating mortality, further work is needed to confirm the validity of these laboratory data. As a result; TPE is a useful, easy and effective life saving treatment with few side effects.

Terapo tik Plazma Deg işimi Endikasyonları, Komplikasyonları ve Yanıtları; Tek Merkez, Retropsektif Analiz Sonuçları

: Terapötik plazma değişimi (TPD) plazmadan yüksek molekül ağırlıklı maddelerin uzaklaştırılmasını sağlayan bir işlemdir. Terapötik plazma değişimi işlemi iç hastalıkları pratiğinde birçok hastalıkta yaygın olarak kullanılmaktadır. Bu işlem ile ilgili son yıllarda farkındalığın ve ulaşılabilirliğin artmasına bağlı olarak güncel kılavuzlar yayımlanmaktadır. Bunlardan en genel geçer ve kapsamlı olanı Amerikan Aferez Cemiyeti (ASFA)’nin yayımladığı kılavuzdur. Bu çalışmada, iç hastalıkları kliniğinde herhangi bir nedenle terapötik plazma değişimi yapılan hastaların demografik verilerini, altta yatan hastalıklarını, biyokimyasal parametrelerini, replasman sıvısının volümü ve tipini, işlem sırasında ve sonrasında gelişen komplikasyonları, ek tedavileri, diyaliz ihtiyacı olup olmadığını, seans sayılarını retrospektif olarak belirleyerek klinik pratikte geliştirilebilecek yönleri ortaya koyabilmek amaçlandı. Çalışmada 2007 ve 2016 yılları arasındaki, 117 hasta retrospektif olarak değerlendirildi. Tüm olguların 63 (%53,8)’ü kadın, 54 (%46,2)’ü erkekti. Tanı anında hastaların yaş ortalaması 52,15 ± 16,8 (20-88) yıl idi. En sık TPD endikasyonu TTP ve ANCA ilişkili vaskülit idi. Taze donmuş plazma ve albümin en sık kullanılan replasman sıvılarıydı. Katater ilişkili komplikasyon oranı %5,1 idi. TPD süresince TPD ilişkili komplikasyon oranı %19,6 idi. TPD işlemi ile ilgili herhangi bir fatal reaksiyona rastlanılmadı. TTP tanılı hastaların başvuru anındaki laboratuvar verileri ile mortalite arasındaki ilişkiye bakıldığında ALP ve mortalite arasında anlamlı bir ilişki bulundu (p= 0.002). ANCA ilişkili vaskülit hastalarında ise klor ve hematokrit ile mortalite arasında anlamlı bir ilişki bulundu (sırasıyla p = 0.029, p= 0.037). Mortaliteyi tahmin etmede kullanım amacıyla, bu laboratuvar verilerinin teyidi için ileri çalışmalara ihtiyaç vardır. Sonuç olarak; TPD, çok az yan etki ile faydalı, kolay ve etkili bir hayat kurtaran tedavi yöntemidir.

PDF

___

Sengul Samanci N, Ayer M, Gursu M, et al. Patients treated with therapeutic plasma exchange: a single center experience. Transfus Apher Sci. 2014;51:83-9.

Eren G, Çukurova Z, Kucur E, et al., Our Experience on Therapeutic Plasmapheresis Performed for A Variety of Clinical Indications in Our Intensive Care Unit Turkiye Klinikleri J Med Sci 2010;30:1683-9

Rock GA, Shumak KH, Buskard NA, et al. Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic purpura. Canadian Apheresis Study Group. N Engl J Med. 1991; 8;325:393-7.

Allford SL, Hunt BJ, Rose P, Machin SJ;Haemostasis and Thrombosis Task Force, British Committee for Standards in Haematology: Guidelines on the diagnosis and management of the thrombotic microangiopathic haemolytic anaemias. Br J Haematol., 2003. 120: p. 556-73.

Scully M, Hunt BJ, Benjamin S, et al., Guidelines on the diagnosis and management of thrombotic thrombocytopenic purpura and other thrombotic microangiopathies. Br J Haematol. 2012;158: 323-35.

Szczepiorkowski ZM, Winters JL, Bandarenko N et al., Guidelines on the use of therapeutic apheresis in clinical practice evidence‐based approach from the apheresis applications committee of the American Society for Apheresis. J Clin Apher. 2010;25:83-177.

Schwartz J, Winters JL, Padmanabhan A,et al., Guidelines on the use of therapeutic apheresis in clinical practice-evidence‐based approach from the Writing Committee of the American Society for Apheresis: the sixth special issue. J Clin Apher. 2013;28:145-284.

Agishi, T., Spectrum of blood purification. Prog Med, 1985;134: 861-64.

Huestis, DW, Bove JR, Busch S. Practical blood transfusion. Little Brown and Company. 1981

Barnes A. Hemapheresis perspectives. Terapeutic Apheresis. Arlington, Virginia: American Association of Blood Banks, 1983: p. 1-13.

Shaz BH, Schwartz J, Winters JL. How we developed and use the American Society for Apheresis guidelines for therapeutic apheresis procedures. Transfusion, 2014;54: 17-25.

Toprak SK, İlhan O. Current Legislation in Therapeutic Apheresis and National Therapeutic Apheresis Guideline: Where Do We Stand in 2015? Turkiye Klinikleri J Hematol-Special Topics 2015;8:104-14

Korkmaz S, Keklik M, Sivgin S et al., Therapeutic plasma exchange in patients with thrombotic thrombocytopenic purpura: a retrospective multicenter study. Transfus Apher Sci. 2013;48:353-8.

Kim JW, Kim I, Oh KH et al., Therapeutic plasma exchange in patients with thrombotic thrombocytopenic purpura–hemolytic uremic syndrome: the 10‐year experience of a single center. Hematology. 2011;16:73-9.

Miller DP, Kaye JA, Shea K, et al., Incidence of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome. Epidemiology. 2004;15:208-15.

Kappler S, Ronan-Bentle S, Graham A. Thrombotic Microangiopathies (TTP, HUS, HELLP). Emerg Med Clin North Am. 2014;32:649-71.

Lane SE, Watts R, Scott DG. Epidemiology of systemic vasculitis. Curr Rheumatol Rep. 2005;7:270-5

Yilmaz AA, Can OS, Oral M, et al., Therapeutic plasma exchange in an intensive care unit (ICU): a 10-year, single-center experience. Transfus Apher Sci. 2011;45:161- 6.

Gwathmey K, Balogun RA, Burns T.. Neurologic indications for therapeutic plasma exchange: 2011 update. J Clin Apher. 2012;27:138-45

Seck SM, Bertrand D, Boucar D. Current indication of plasma exchanges in nephrology: a systematic review. Saudi J Kidney Dis Transpl. 2011;22:219-24.

Kaplan, AA. A practical guide to therapeutic plasma exchange. 1999: Blackwell Science. 22. Mokrzycki MH, Kaplan AA. Therapeutic plasma exchange: complications and management. Am J Kidney Dis. 1994;23:817- 27.

Passalacqua S, Staffolani E, Busnach G, et al., The Italian registry for therapeutic apheresis. A report from the apheresis study group of the Italian society of nephrology. J Clin Apher. 2005;20:101-6.

Bramlage CP, Schröder K, Bramlage P, et al., Predictors of complications in therapeutic plasma exchange. J Clin Apher. 2009;24:225- 31.

Szczeklik W, Wawrzycka K, Włudarczyk A et al., Complications in patients treated with plasmapheresis in the intensive care unit. Anaesthesiol Intensive Ther. 2013;45:7-13.

Benítez C, Andresen M, Farías G, et al., Indications, adverse effects and results of plasmapheresis in critical care patients. Rev Med Chil. 2005;133:1441-8

Moake, JL. Thrombotic microangiopathies. N Engl J Med. 2002;347:589-600.

Kessler CS, Khan BA, Lai-Miller K. Thrombotic thrombocytopenic purpura: a hematological emergency. J Emerg Med. 2012;43:538-44.

Ridolfi RL, Bell WR. Thrombotic thrombocytopenic purpura: Report of 25 cases and review of the literature. Medicine (Baltimore). 1981;60:413-28.

Noris M, Remuzzi G. Hemolytic uremic syndrome. J Am Soc Nephrol. 2005;16:1035- 50

George, JN. How I treat patients with thrombotic thrombocytopenic purpura– hemolytic uremic syndrome. Blood. 2000; 15;96:1223-9.

Haas M, Böhmig GA, Leko-Mohr Z, et al. Peri‐operative immunoadsorption in sensitized renal transplant recipients. Nephrol Dial Transplant. 2002;17:1503-8.

Yin H, Hu XP, Li X, et al., Protein A immunoadsorption combined with rituximab in highly sensitized kidney transplant recipients. Chin Med J (Engl). 2009;122:2752- 6.

Keskin A, Cagirgan S, Cetin M, Buyukkececi M. Thrombotic thrombocytopenic purpura: Report of 10 cases. Turkish J. Med. Sci, 1995. 24: 155–158.

Barz D. Budde U, Hellstern P. Therapeutic plasma exchange and plasma infusion in thrombotic microvascular syndromes. Thromb Res. 2002; 107 :23-7.

Stefanello B, De Paula EV, Andrade Orsi F et al. Safety and efficacy of cryoprecipitate‐poor plasma as a replacement fluid for therapeutic plasma exchange in thrombotic thrombocytopenic purpura: A single center retrospective evaluation. J Clin Apher. 2014 ;29:311-5

Kaya E, Keklik M, Sencan M, et al. Therapeutic plasma exchange in patients with neurological diseases: multicenter retrospective analysis. Transfus Apher Sci. 2013;48:349-52

Erkurt MA, Kuku I, Kaya E, et al., Therapeutic plasma-exchange in hematologic disease: Results from a single center in Eastern Anatolia. Transfus Apher Sci. 2013;48:335-9

Guptill JT, Oakley D, Kuchibhatla M, et al. A retrospective study of complications of therapeutic plasma exchange in myasthenia. Muscle Nerve. 2013;47:170-6.

McGuckin S, Westwood JP, Webster H, et al. Characterization of the complications associated with plasma exchange for thrombotic thrombocytopaenic purpura and related thrombotic microangiopathic anaemias: a single institution experience. Vox Sang. 2014;106:161-6.

Pereira A, Mazzara R, Monteagudo J, et al. Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome: a multivariate analysis of factors predicting the response to plasma exchange. Ann Hematol. 1995;70:319-23.

Patton JF, Manning KR, Case D, Owen J. Serum lactate dehydrogenase and platelet count predict survival in thrombotic thrombocytopenic purpura. Am J Hematol. 1994;47:94-9.

Hollenbeck M, Kutkuhn B, Aul C, et al. Haemolytic-uraemic syndrome and thrombotic-thrombocytopenic purpura in adults: clinical findings and prognostic factors for death and end-stage renal disease. Nephrol Dial Transplant. 1998;13:76-81.

Levandovsky M, Harvey D, Lara P, Wun T. Thrombotic thrombocytopenic purpurahemolytic uremic syndrome (TTP-HUS): a 24- year clinical experience with 178 patients. J Hematol Oncol. 2008 ;1;1:23.

Goel R, King KE, Takemoto CM, Ness PM, Tobian AA Prognostic risk‐stratified score for predicting mortality in hospitalized patients with thrombotic thrombocytopenic purpura: nationally representative data from 2007 to 2012. Transfusion. 2016;56:1451-8.

Hogan SL, Nachman PH, Wilkman AS, Jennette JC, Falk RJ., Prognostic markers in patients with antineutrophil cytoplasmic autoantibody-associated microscopic polyangiitis and glomerulonephritis. J Am Soc Nephrol. 1996;7:23-32.

Weiner M, Goh SM, Mohammad AJ, et al. Outcome and treatment of elderly patients with ANCA-associated vasculitis. Clin J Am Soc Nephrol. 2015;10:1128-35.

Lai QY, Ma TT, Li ZY et al. Predictors for mortality in patients with antineutrophil cytoplasmic autoantibody-associated vasculitis: a study of 398 Chinese patients. J Rheumatol. 2014;41:1849-55.

Huestis D. Mortality in therapeutic haemapheresis. Lancet. 1983;1:1043.

Harris, T, Hillyer C. Technical manual. 2011.

Andre A Kaplan, Joy L Fridey. Therapeutic apheresis (plasma exchange or cytapheresis): Complications. www.uptodate.com ©2017 UpToDate