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PubMed1986

Phenytoin removal by plasmapheresis in renal insufficiency.

The removal of phenytoin by plasmapheresis in a patient with compromised renal function is described. The results indicate that plasma concentrations of total phenytoin increase after plasmapheresis, while unbound phenytoin plasma concentrations and free fraction decrease. The amount of phenytoin removed was 36 mg and, when expressed as a fraction of total body stores, equaled 2.8%. The negligible amount of total body phenytoin removed during plasmapheresis was the result of an increased volume of distribution due to renal failure and hypoalbuminemia. Our results indicate that the removal of phenytoin by plasmapheresis is likely to be greatest when its free fraction is the lowest and blood flow the highest. The data suggest that replacement of phenytoin after plasma exchange may be unnecessary but in all cases should be based on unbound concentrations or the determination of the absolute amount of phenytoin removed during the procedure.

Adult↗
PubMed1979

Plasmapheresis in Crohn's disease.

6 patients with Crohn's disease for 1-14 years have been treated with plasmapheresis for periods of up to 6 months. The symptoms of the one newly diagnosed patient were controlled by plasmapheresis alone, and 5 steroid-dependent patients were able to reduce their steroid requirements. During the study period, 13 clinical relapses were managed without increasing steroid dosage. There was evidence of circulating soluble immune complexes in all the patients and these levels were lowered by plasmapheresis. A possible role of plasmapheresis in the management of Crohn's disease is discussed.

Adult↗
PubMed1981

Propranolol plasma concentrations and plasmapheresis.

Propranolol plasma concentrations were determined in a patient with hemolytic-uremic syndrome undergoing plasmapheresis before and after the procedure on three occasions. The mean half-life and elimination rate constant during plasmapheresis were estimated to be 25.6 percent of the values obtained without plasmapheresis. These changes suggest that plasmapheresis may influence propranolol disposition.

Adult↗
PubMed1994

Islet cell antibodies, but not glutamic acid decarboxylase antibodies, are decreased by plasmapheresis in patients with newly diagnosed insulin-dependent diabetes mellitus.

The effects of plasmapheresis on islet autoantibody levels, C-peptide (beta-cell function), and hemoglobin-A1c (HbA1c, metabolic control) were tested in a prospective blinded study of 18 newly diagnosed insulin-dependent diabetes mellitus (IDDM) patients randomly assigned to receive plasmapheresis (P), carried out as double filtration, or sham (S) treatment at diagnosis and 3 months thereafter. At diagnosis, 6 of 8 patients (75%) in group P and 9 of 10 patients (90%) in group S had islet cell antibodies (ICA), whereas 4 of 8 (50%) and 7 of 10 (70%) patients, respectively, had glutamic acid decarboxylase antibodies (GAD65-Ab), with no significant differences between the groups in ICA and GAD65-Ab levels. After 6 months, P patients showed significantly lower ICA levels than S patients (11 +/- 6 and 128 +/- 47 Juvenile Diabetes Foundation International Units, respectively; P < 0.02) due to an increase in ICA levels in 8 of 9 (88%) of the S patients not seen in P patients (P < 0.002). Concurrently, HbA1c stabilized in P, but not in S, patients and was significantly lower by 24 months (6.58 +/- 0.54% vs. 9.76 +/- 1.21%; P < 0.05). Moreover, fasting C-peptide increased significantly (214 +/- 11 pmol/L; P < 0.05) over the first 6 months in P. After the initial 6 months, ICA levels tended to decrease in all patients and were not detected after 60 months. GAD65-Ab levels were not influenced by plasmapheresis and, also in contrast to ICA, increased significantly (P < 0.05) in the whole study population after 60 months. In fact, 4 initially negative patients became GAD65-Ab positive after diagnosis (in 2 patients > 24 months after diagnosis). We conclude that plasmapheresis of newly diagnosed IDDM patients does not change subsequent GAD65-Ab levels, but ICA are significantly decreased with associated improved C-peptide and HbA1c levels.

Adolescent↗
PubMed1980

Plasmapheresis in multiple sclerosis: preliminary findings.

In seven of eight patients with progressive multiple sclerosis subjected to long-term plasmapheresis in combination with azathioprine and pulsed prednisone therapy, we found modest improvement of neurologic function. There was no change in auditory and visual evoked responses or serum demyelinating activity. In six of seven patients, cerebrospinal fluid IgG content decreased. Three additional patients in acute, severe exacerbation refractory to prednisone therapy made a substantial recovery, which commenced with plasmapheresis therapy. In two of them, the onset of clinical improvement after plasmapheresis was corroborated by decreased latency or increased amplitude of somatosensory evoked potentials. These results suggest that blood-borne factors, possibly autoantibodies, may play a role in the pathogenesis of the disease. The lesions may be at least partially reversible with plasmapheresis therapy, but a controlled trial is necessary to confirm these preliminary findings.

Adult↗
PubMed1980

Plasmapheresis in multiple sclerosis: preliminary study.

In six of eight patients with chronic progressive multiple sclerosis (MS) who were previously unresponsive to corticosteroid medication, moderate but unequivocal improvement occurred after short-term plasmapheresis, prednisone, and azathioprine therapy. In four patients, improvement gradually disappeared in the 2 to 3 months after therapy, and two patients have remained improved. There were no exacerbations during the treatment period. No consistent improvement in evoked response batteries was seen after plasmapheresis; IgG levels in cerebrospinal fluid were lowered by plasmapheresis. A controlled trial to determine the efficacy of plasmapheresis in the treatment of MS is warranted.

Adult↗
PubMed1996

Plasmapheresis in Rasmussen's encephalitis.

Rasmussen's encephalitis (RE) is a progressive childhood disorder characterized by intractable focal seizures, hemiplegia, dementia, and inflammatory histopathology. The process is typically limited to one cerebral hemisphere. We report four patients with pathologically confirmed RE who were treated with repeated plasmapheresis. Three patients exhibited repeated, dramatic, transient responses to plasmapheresis, manifested by reduced seizure frequency and improved neurologic function. One patient exhibited marginal improvement after treatment with plasmapheresis. These observations indicate that circulating factors, likely autoantibodies, are pathogenic in at least some patients with RE and suggest that RE is an autoimmune disease. Plasmapheresis may be a useful adjunctive therapy in status epilepticus, and can also aid in assessment of residual function in the diseased hemisphere before surgical resection.

Adolescent↗
PubMed2005

Acute disseminated encephalomyelitis in children: discordant neurologic and neuroimaging abnormalities and response to plasmapheresis.

OBJECTIVES: To describe our experience with acute disseminated encephalomyelitis (ADEM), focusing on (1) the relationship between clinical course and MRI findings and (2) the response to plasmapheresis in a subgroup of patients. METHODS: A retrospective record review was conducted of 13 children who were admitted as inpatients with the diagnosis of ADEM during the period 1998-2003. RESULTS: Diagnosis was established by clinical signs and symptoms, cerebrospinal fluid changes and multifocal involvement of deep gray and white matter based on MRI. Initial therapy was high-dose methylprednisolone and intravenous immunoglobulin in 12 patients. One child improved spontaneously. Six of 12 children did not improve with corticosteroid treatment. All 6 had an acute progressive course neurologically, and 5 of them also showed a delay in the onset of neuroimaging changes, eventually developing lesions in the deep gray matter and brainstem. This latter group received 5 sessions of plasmapheresis and recovered over the course of several months with varying degrees of residual neurologic deficits. CONCLUSIONS: Presentation of ADEM with delayed development of MRI lesions in deep gray matter and brainstem may herald a prolonged clinical course and lack of response to glucocorticoid therapy. Plasmapheresis might be an effective therapeutic intervention in these patients. The role of plasmapheresis versus corticosteroids and intravenous immunoglobulin as a primary treatment of ADEM needs to be investigated further.

Adolescent↗
PubMed1992

[Plasmapheresis in neurology. Critical analysis of indications and protocols].

Therapeutic plasmapheresis (plasma exchange) in neurology is a matter of discussion. We review the main articles on clinical trials, both controlled and uncontrolled, trying to establish the efficacy and safety of the procedure. Humoral aspects involved in the genesis of the disorder play an important role for its indication in the present time. In myasthenia gravis indications for plasmapheresis are established: in the preparation for thymectomy, in patients with respiratory insufficiency and requiring respiratory prosthesis, after long immunosuppression therapy with rebound effect, when all other forms of therapy failed, and in neonatal myasthenia gravis with special technics. We discuss the indication of plasmapheresis in Guillain-Barré syndrome, multiple sclerosis, chronic inflammatory demyelinating polyneuromyelopathy, HTLV-1 myelopathy, HIV peripheral neuropathy and myelopathy, paraproteinemias, polymyositis, and dermatomyositis. Indications for other diseases are mentioned. Reference is made to the results we observed in 31 cases followed consecutively at Hospital dos Servidores, Rio de Janeiro, from June 1984 to June 1990. In our series 26 were myasthenic patients, 4 patients presented Guillain-Barré syndrome, and 1 multiple sclerosis. Therapeutic plasmapheresis protocols suggested by us are summarized.

Adolescent↗
PubMed1984

A prospective analysis of islet-cell cytotoxic antibodies in insulin-dependent diabetic children. Transient effects of plasmapheresis.

We determined the effects of plasmapheresis on cytotoxic antibodies to islet cells in 10 children (aged 11-16 yr) with newly diagnosed insulin-dependent diabetes mellitus (IDDM), as well as the plasma levels of antibodies over the next 30 mo and their relation to serum C-peptide concentrations. Complement-dependent, antibody-mediated cytotoxicity (C'AMC) in plasma was measured in a 51Cr release assay using monolayers of the rat islet cell line RINm5F. Cytotoxic antibodies decreased in most IDDM subjects treated by plasmapheresis four times within 2 wk of diagnosis; however, the decreases were small and lasted less than 2-3 days. Thus, both before and after plasmapheresis, 7 of the 10 IDDM children were C'AMC-positive (51Cr release greater than 2 SD above mean for 13 healthy children). After 18-30 mo, only 2 of the original 7 IDDM children with C'AMC-positive plasmas were still positive, and 1 of the original 3 IDDM children without significant cytotoxicity had become positive. Meal-stimulated serum C-peptide responses, measured from diagnosis to 18-30 mo later, did not correlate with C'AMC values. We conclude that (1) plasmapheresis has only transient effects on islet-cytotoxic antibody levels in children with IDDM; (2) these antibodies decrease in most, but not all, subjects over the first 18 mo after diagnosis; and (3) the level of cytotoxic antibodies in IDDM plasma at diagnosis has no predictive effect on residual B-cell function.

Adolescent↗
PubMed1993

Plasmapheresis in the treatment of primary septic shock in humans.

14 patients (mean age 25.5 yrs) with life-threatening primary septic shock were eligible for treatment with acute plasmapheresis in a prospective study. They had a short history of sepsis and had no severe underlying disease. 10/14 patients had systemic meningococcal disease. All patients were severely ill with a mean APACHE II score of 25.0. 12/14 patients were treated with plasmapheresis exchanging 1 plasma volume within hours of admission. 11/14 patients survived without major sequelae and 3 (21%) died of irreversible septic shock. This mortality is lower than that predicted from the APACHE II scores (55.2%). A subgroup of plasmapheresis-treated patients with septic shock and extensive petechiae were compared to a historical control group. The mortality in the treatment group was 1/7 (14%) versus 8/21 (38%) in the control group. We conclude that acute plasmapheresis may be a therapeutic option in the early stages of severe primary non-surgical septic shock.

Adolescent↗
PubMed2000

Plasmapheresis in life-threatening verapamil intoxication.

Verapamil intoxications are life-threatening conditions with a far too often fatal outcome. In 2 patients, severe suicidal intoxication by 2.4 g and 9.6 g of verapamil orally resulted in life threatening hypotension and bradycardia with the need of heart-pacing and resuscitation. Plasmapheresis was started within less then 4 hours after intoxication and seemed to reduce the verapamil plasma concentration to less then 40%. A dramatic improvement of cardiovascular stability was already observed during plasmapheresis. In-vitro plasmapheresis was performed to verify the effectiveness of the extracorporeal detoxification. Verapamil was removed out of the blood by a clearance of 29.2 ml/min at blood flow of 200 ml/min. In conclusion, severe verapamil poisoning should be treated by early aggressive gut decontamination and an appropriate management of the haemodynamic complications. In case of lack of effectiveness for stabilisation, plasmapheresis can reduce verapamil related life threatening symptoms and bridge the time for the hepatic detoxification.

Acute Disease↗
PubMed2004

[Plasmapheresis in neurological diseases. Experience in 140 procedures in 47 patients].

BACKGROUND: Plasmapheresis can be useful in myasthenia gravis, Guillain Barré syndrome and chronic demyelinating inflammatory polyradiculoneuritis. AIM: To report our experience with plasmapheresis in patients with neurological diseases. MATERIAL AND METHODS: Retrospective review of plasmapheresis procedures done between 1995 and 2001, in a public hospital. Indications criteria, clinical results and technical yield were analyzed. RESULTS: One hundred fifty nine procedures were reviewed. One hundred forty (88%) were indicated for neurological diseases (44% for Guillain Barré syndrome and 29% for myasthenia gravis). Clinical improvement or eventual complications were avoided in 70% of patients with Guillain Barré syndrome and 100% of patients with myasthenia gravis. Hypotension in 10% and paresthesias in 7% were observed. All complications were successfully controlled with crystalloid or fresh plasma infusions or citrate management. In 11 cases, the procedure was interrupted due to obstruction of the venous access, that was peripheral in eight of these. The most common difficulties of the procedure were delay in performing it in 50% of patients and insufficient exchange volumes in 30%. CONCLUSIONS: Plasmapheresis was safe and useful in patients with myasthenia gravis and Guillain Barré syndrome. The drawbacks of the procedure are its costs and requirement of special equipment.

Adult↗
PubMed2006

[Indications, adverse effects and results of plasmapheresis in critical care patients].

BACKGROUND: Plasmapheresis is a therapeutic alternative for diseases in which a "humoral factor" has pathogenetic relevance. However it is not devoid of adverse effects. AIM: To review the indications, number of procedures, morbidity and clinical evolution of plasmapheresis in critical patients. PATIENTS AND METHODS: A retrospective and descriptive study in four intensive care units of an University hospital. The severity of patients was evaluated with APACHE II and SOFA scores. RESULTS: Twenty patients were studied. The most common indications of plasmapheresis were thrombotic thrombocytopenic purpura (TTP) in 50% of subjects and small vessel vasculitides in 30%. The number of procedures per patient oscillated between 2 and 14 (mean: 7.1+/-3.3). The registered adverse effects were hypocalcemia in 50% of patients, hypotension in 42.1%, coagulopathy in 35%, hypokalemia in 29%, rash in 20%, procedure related infections in 18% and fever in 10%. There was a significant decrease of 17+/-28% in prothrombin time, after the procedures. Seventy five percent of patients had a favorable evolution. Global mortality rate was 15%. All deaths occurred in patients with TTP and were attributed to the progression of the disease. No death was attributed to the procedure. The initial APACHE II and SOFA scores were 12.4+/-8.4 and 5.3+/-2.9, respectively. Both scores decreased after the procedure. Among other therapeutic measures, 15% of the patients received immunosuppressant treatment, 27% were dialyzed and 32% were mechanically ventilated. CONCLUSIONS: The most common indication of plasmapheresis was TTP. Adverse effects were frequent, however there was no procedure related mortality. The global mortality rate was 15% and all deaths occurred in patients with TTP.

APACHE↗
PubMed1999

[Use of plasmapheresis in patients with AIDS and peripheral polyneuropathy].

The plasmapheresis is procedure removal of plasma and simultaneously, together with plasma, toxins, incorrect metabolites, antigens and immunological complexes. In patients with HIV infection often appearance periphery polyneuropathy. This is connected with autoantibody action on the damage of neurone. The aim of this study was evaluation effectiveness of plasmapheresis in treatment patients with AIDS and polyneuropathy. Seven patients with AIDS--C3 and polyneuropathy coexistence were treatment by plasmapheresis. The symptoms of polyneuropathy decrease in all patients. Were don't influence on immunological system and side effect performance plasmapheresis.

Acquired Immunodeficiency Syndrome↗
PubMed2000

Experience in the treatment of myasthenia gravis with double filtration plasmapheresis.

BACKGROUND: Myasthenia gravis (MG) is an autoimmune disease characterized by production of autoantibodies directly against acetylcholine receptors on postjunctional membranes. The treatment modalities of myasthenia gravis include cholinesterase inhibitors, surgical thymectomy, immunosuppressive treatment, and short-term immunotherapies, including plasmapheresis and intravenous immune globulin. Double filtration plasmapheresis (DFP) is a new technique of plasmapheresis. The aim of our study is to evaluate the effectiveness and complications of DFP in the treatment of MG. METHODS: From December, 1993 to August, 1998, a total of 33 patients with MG received 68 courses (total of 299 sessions) of DFP in our hospital. Plasmapheresis volume, drainage volume, treatment duration, heparin dose, and complications were recorded. In addition, clinical responses after DFP were also evaluated. RESULTS: Only 4 courses (5.88%) of treatment were ineffective. Sixty-four courses (94.12%) of treatment lessened disease activity. The complications of DFP included 15 episodes of hypotension (5.01%), 2 of bradycardia (0.67%), 3 of chest pain (1.00%), 7 of dizziness (2.34%), 58 of high transmembranous pressure of plasma separator (19.40%), 3 of high secondary pressure of plasma fractionator (1.00%), 12 of hemolysis (4.01%), 2 of plasma separator clot (0.67%), 2 of plasma fractionator clot (0.67%), 3 of blood leakage (1.00%), and 1 of air embolism (0.33%). There was no mortality associated with the DFP procedure. CONCLUSION: DFP is a safe, convenient, and time-saving therapy with rare severe complications in the treatment of MG. Our experience confirms its effectiveness when used in combination with drug therapy and thymectomy.

Adult↗
PubMed2000

Tacrolimus (FK 506) induced thrombotic thrombocytopenic purpura after ABO mismatched second liver transplantation: salvage with plasmapheresis and prostacyclin.

We report the course of thrombotic thrombocytopenic purpura (TTP) in a patient receiving tacrolimus (FK506) immunosuppression for an ABO mismatched second liver graft. A Chinese woman with fulminant hepatitis-B reactivation failed a living-related orthotopic liver transplantation (OLT) due to portal vein thrombosis. An ABO mismatched cadaveric OLT (group A to O) was performed, with peri-operative plasmapheresis to reduce anti-A hemagglutinin titers. On day 30, she developed fever, hemolysis, thrombocytopenia and neurologic dulling. Prominent microangiopathic features in peripheral blood film, and characteristic brain lesions on magnetic resonance imaging confirmed TTP. She responded initially to intensive plasmapheresis with cryosupernatant replacement, and withdrawal of FK506. An attempted reintroduction of FK506 for threatened rejection led to TTP exacerbation. This was controlled with prolonged plasmapheresis and a ten-day infusion of prostacyclin. Immunosuppression was changed to mycophenolate mofetil. By day 53, the peripheral film and lactate dehydrogenase level had returned to baseline and plasmapheresis was stopped.

ABO Blood-Group System↗
PubMed1999

Plasmapheresis during cardiopulmonary bypass: a proposed treatment for presensitized cardiac transplantation patients.

Potential thoracic organ transplantation recipients who have positive cytotoxic antibody screens as quantified panel reactive antibodies (PRA) are at risk for immediate or long-term immunologic events that may affect the donor organ. The patient population at risk includes those who are supported with cardiac assist devices, multiparous women, and individuals receiving numerous homologous blood products. We treated three highly positive PRA patients with intraoperative plasmapheresis coupled to the cardiopulmonary bypass system to remove sufficient cytotoxic antibody. Upon the availability of donor hearts of an unknown HLA type, intraoperative plasmapheresis was performed using a Cobe Spectra Plasmapheresis system coupled to a Terumo CXSX18 oxygenator system. Three plasma volume exchanges of fresh frozen plasma (FFP) were performed while the patients were on cardiopulmonary bypass. One to one and one-half plasma volume exchange plasmaphereses were performed with a declining schedule for the next 30 days post-transplantation in combination with aggressive B-cell specific immunosuppressive therapy. The three patients are NYHA functional class I and free of rejection at 6 months post-transplantation. In conclusion, intraoperative plasmapheresis is effective and safe for the patient who would not be otherwise transplanted because of markedly elevated PRAs.

Adult↗