Therapeutic Apheresis: A single center experience

Abstract

Background: Therapeutic Apheresis (TA) is a procedure consisting of the removal of a pathogenic substance from a patient's blood by an extracorporeal medical device. The component substitution solution is determined by the disease to be treated, and the effectiveness of the procedure depends on the patient's blood concentration, processed volume and the equilibrium between blood and the extravascular fluid distribution. The actual guidelines for using TA, in a wide variety of diseases are increasing, as primary or adjunct therapy Aims: Evaluate the activity of Therapeutic Apheresis procedures in the last 6 years, in our Center. Method(s): Retrospective review of all TA performed from 2011 to 2016. 368 procedures were analyzed in 25 patients. All the procedures were done by continuous flow method using the COBE Spectra system. The indications, clinical results and technical factors are discussed. Result(s): 18 patients were submitted to Therapeutic Plasma Exchange (TPE) due to thrombotic thrombocytopenic purpura (TTP) and haemolytic uremic syndrome (1). In 4 patients a possible trigger was suggested: one patient after Escherichia coli intestinal infection, another after pneumococcal vaccination and 2 patients after pregnancy (one congenital and the other acquired TTP). The other cases were considered idiopathic. TPE was performed daily using inactivated human plasma as replacement solution exchanging 1-1.5 total plasma volume, until the platelet count was above 150 x109/l and lactate dehydrogenase near normal for 2-3 consecutive days. In all these patients corticosteroids were used as an adjunct therapy at 1 mg/kg/day. Rituximab was also used in refractory or relapsing TTP cases. 3 patients had Waldenstrom's macroglobulinemia with IgM levels >30 g/l and hyperviscosity symptoms. Daily procedures exchanged one plasma volume with a Human albumin 5% solution. The clinical response was considered excellent, except in one patient with deterioration of the clinical condition due to preexisting illness. TPE was also performed in 4 patients with demyelinating disease (3 multiple sclerosis and 1 neuromyelitis optica (NMO)) unresponsive to steroids, as a second-line therapeutic option, associated to immunosuppressive medication and immunomodulation. Initially daily and afterwards every other day procedures as deemed necessary (e.g.: in NMO), one plasma volume was exchanged with a human albumin 5% solution with satisfactory clinical and imagiological outcomes. The implementation of RBCs exchange was initiated in 2015: 3 procedures in 2 Sickle Cell Disease patients (one homozygotic (SS) and another heterozygous compound (SC)) with HbS >30%, to prevent secondary stoke and to treat chronic debilitating pain. Summary/Conclusions: The analysis of TA in our department shows that the procedure was secure. Although hypotension and fluid-electrolyte imbalance may occur, most of these problems were readily reversed. Nowadays in our Centre TA is performed in the field of Haematology and Neurology mostly, but it could play a significant role in the patient therapeutic strategy, in an extensive variety of diseases. Using an evidence-based approach is the best way to standardize care and to provide a platform for innovation to move the field forward. To achieve this, we encourage the sharing of the apheresis centres' experiences so as to reinforce and improve evidence levels and provide a knowledge base to update existing guidelines.