Therapeutic Plasma Exchange Indications, Complications and Responses in Internal Medicine Patients: A Single Center, Retrospective Analysis

Yıl 2020, Cilt: 42 Sayı: 1, 14 - 26, 01.01.2020

Buğra Özkan Hava Üsküdar Teke , Döndü Üsküdar Cansu Garip Şahin

https://doi.org/10.20515/otd.462835

Öz

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.

Anahtar Kelimeler

therapeutic plasma exchange, ttp, anca-associated vasculitis

Terapötik Plazma Değişimi Endikasyonları, Komplikasyonları ve Yanıtları; Tek Merkez, Retrospektif Analiz Sonuçları

Öz

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.

Anahtar Kelimeler

terapötik plazma değişimi, ttp, anca ilişkili vaskülit

Kaynakça

• 1. Samanci, N.S., et al., Patients treated with therapeutic plasma exchange: a single center experience. Transfusion and Apheresis Science, 2014. 51(3): p. 83-89.2. EREN, G., et al., Yoğun bakım ünitemizde çeşitli endikasyonlarla uyguladığımız terapötik plazmaferez deneyimlerimiz. Turkiye Klinikleri Journal of Medical Sciences, 2010. 30(5): p. 1683-1689.3. Rock, G.A., et al., Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic purpura. New England Journal of Medicine, 1991. 325(6): p. 393-397.4. Allford, S., 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. 556-573.5. Scully, M., et al., Guidelines on the diagnosis and management of thrombotic thrombocytopenic purpura and other thrombotic microangiopathies. British journal of haematology, 2012. 158(3): p. 323-335.6. Szczepiorkowski, Z.M., 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. Journal of clinical apheresis, 2010. 25(3): p. 83-177.7. Schwartz, J., 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. Journal of clinical apheresis, 2013. 28(3): p. 145-284.8. Agishi, T., Spectrum of blood purification. Prog Med, 1985. 134(10): p. 861-864.9. Huestis, D.W., J.R. Bove, and S. Busch, Practical blood transfusion. 1981: Little Brown and Company.10. Barnes, A., Hemapheresis perspectives. Terapeutic Apheresis. Arlington, Virginia: American Association of Blood Banks, 1983: p. 1-13.11. Shaz, B.H., J. Schwartz, and J.L. Winters, How we developed and use the American Society for Apheresis guidelines for therapeutic apheresis procedures. Transfusion, 2014. 54(1): p. 17-25.12. TOPRAK, S.K. and O. İLHAN, Terapötik Aferezde Yasal Mevzuat ve Ulusal Terapötik Aferez Rehberi: 2015'te Neredeyiz? Turkiye Klinikleri Journal of Hematology Special Topics, 2015. 8(1): p. 104-114.13. Korkmaz, S., et al., Therapeutic plasma exchange in patients with thrombotic thrombocytopenic purpura: a retrospective multicenter study. Transfusion and Apheresis Science, 2013. 48(3): p. 353-358.14. Kim, J.W., 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(2): p. 73-79.15. Miller, D.P., et al., Incidence of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome. Epidemiology, 2004. 15(2): p. 208-215.16. Kappler, S., S. Ronan-Bentle, and A. Graham, Thrombotic Microangiopathies (TTP, HUS, HELLP). Emergency Medicine Clinics, 2014. 32(3): p. 649-671.17. Lane, S.E., R. Watts, and D.G. Scott, Epidemiology of systemic vasculitis. Current rheumatology reports, 2005. 7(4): p. 270-275.18. Yilmaz, A.A., et al., Therapeutic plasma exchange in an intensive care unit (ICU): a 10-year, single-center experience. Transfusion and Apheresis Science, 2011. 45(2): p. 161-166.19. Gwathmey, K., R.A. Balogun, and T. Burns, Neurologic indications for therapeutic plasma exchange: 2011 update. Journal of clinical apheresis, 2012. 27(3): p. 138-145.20. Seck, S.M., D. Bertrand, and D. Boucar, Current indication of plasma exchanges in nephrology: a systematic review. Saudi Journal of Kidney Diseases and Transplantation, 2011. 22(2): p. 219.21. Kaplan, A.A., A practical guide to therapeutic plasma exchange. 1999: Blackwell Science.22. Mokrzycki, M.H. and A.A. Kaplan, Therapeutic plasma exchange: complications and management. American Journal of Kidney Diseases, 1994. 23(6): p. 817-827.23. Passalacqua, S., et al., The Italian registry for therapeutic apheresis. A report from the apheresis study group of the Italian society of nephrology. Journal of clinical apheresis, 2005. 20(2): p. 101-106.24. Bramlage, C.P., et al., Predictors of complications in therapeutic plasma exchange. Journal of clinical apheresis, 2009. 24(6): p. 225-231.25. Szczeklik, W., et al., Complications in patients treated with plasmapheresis in the intensive care unit. Anaesthesiology intensive therapy, 2013. 45(1): p. 7-13.26. Benítez, C., et al., Indications, adverse effects and results of plasmapheresis in critical care patients. Revista medica de Chile, 2005. 133(12): p. 1441-1448.27. Moake, J.L., Thrombotic microangiopathies. N Engl j Med, 2002. 2002(347): p. 589-600.28. Kessler, C.S., B.A. Khan, and K. Lai-Miller, Thrombotic thrombocytopenic purpura: a hematological emergency. The Journal of emergency medicine, 2012. 43(3): p. 538-544.29. Ridolfi, R.L. and W.R. Bell, Thrombotic thrombocytopenic purpura: Report of 25 cases and review of the literature. Medicine, 1981. 60(6): p. 413-428.30. Noris, M. and G. Remuzzi, Hemolytic uremic syndrome. Journal of the American Society of Nephrology, 2005. 16(4): p. 1035-1050.31. George, J.N., How I treat patients with thrombotic thrombocytopenic purpura–hemolytic uremic syndrome. Blood, 2000. 96(4): p. 1223-1229.32. Haas, M., et al., Peri‐operative immunoadsorption in sensitized renal transplant recipients. Nephrology Dialysis Transplantation, 2002. 17(8): p. 1503-1508.33. Yin, H., et al., Protein A immunoadsorption combined with rituximab in highly sensitized kidney transplant recipients. Chinese medical journal, 2009. 122(22): p. 2752-2756.34. A. Keskin, M.T., S. Cagirgan, M. Cetin, and F. Buyukkececi, Thrombotic thrombocytopenic purpura: Report of 10 cases. Turkish J. Med. Sci, 1995. 24(2): p. 155–158.35. Barz, D., U. Budde, and P. Hellstern, Therapeutic plasma exchange and plasma infusion in thrombotic microvascular syndromes. Thrombosis research, 2002. 107: p. S23-S27.36. Stefanello, B., 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. Journal of clinical apheresis, 2014. 29(6): p. 311-315.37. Kaya, E., et al., Therapeutic plasma exchange in patients with neurological diseases: multicenter retrospective analysis. Transfusion and Apheresis Science, 2013. 48(3): p. 349-352.38. Erkurt, M.A., et al., Therapeutic plasma-exchange in hematologic disease: Results from a single center in Eastern Anatolia. Transfusion and Apheresis Science, 2013. 48(3): p. 335-339.39. Guptill, J.T., et al., A retrospective study of complications of therapeutic plasma exchange in myasthenia. Muscle & nerve, 2013. 47(2): p. 170-176.40. McGuckin, S., et al., Characterization of the complications associated with plasma exchange for thrombotic thrombocytopaenic purpura and related thrombotic microangiopathic anaemias: a single institution experience. Vox sanguinis, 2014. 106(2): p. 161-166.41. Pereira, A., et al., Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome: a multivariate analysis of factors predicting the response to plasma exchange. Annals of hematology, 1995. 70(6): p. 319-323.42. Patton, J.F., et al., Serum lactate dehydrogenase and platelet count predict survival in thrombotic thrombocytopenic purpura. American journal of hematology, 1994. 47(2): p. 94-99.43. Hollenbeck, M., et al., Haemolytic-uraemic syndrome and thrombotic-thrombocytopenic purpura in adults: clinical findings and prognostic factors for death and end-stage renal disease. Nephrology Dialysis Transplantation, 1998. 13(1): p. 76-81.44. Levandovsky, M., et al., Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS): a 24-year clinical experience with 178 patients. Journal of hematology & oncology, 2008. 1(1): p. 23.45. Goel, R., et al., Prognostic risk‐stratified score for predicting mortality in hospitalized patients with thrombotic thrombocytopenic purpura: nationally representative data from 2007 to 2012. Transfusion, 2016. 56(6): p. 1451-1458.46. Hogan, S.L., et al., Prognostic markers in patients with antineutrophil cytoplasmic autoantibody-associated microscopic polyangiitis and glomerulonephritis. Journal of the American Society of Nephrology, 1996. 7(1): p. 23-32.47. Weiner, M., et al., Outcome and treatment of elderly patients with ANCA-associated vasculitis. Clinical Journal of the American Society of Nephrology, 2015. 10(7): p. 1128-1135.48. Lai, Q.-y., et al., Predictors for mortality in patients with antineutrophil cytoplasmic autoantibody-associated vasculitis: a study of 398 Chinese patients. The Journal of rheumatology, 2014. 41(9): p. 1849-1855.49. Huestis, D., Mortality in therapeutic haemapheresis. The Lancet, 1983. 321(8332): p. 1043.50. Harris, T. and C. Hillyer, Technical manual. 2011.51. Andre A Kaplan, J.L.F., Therapeutic apheresis (plasma exchange pr cytapheresis): Complications. 2017.