Julian Emonds (Leipzig/ DE), Philipp Menzel (Leipzig/ DE), Ruth Schneider (Leipzig/ DE), Kristof Eidam (Leipzig/ DE), Natalia Thriemer (Leipzig/ DE), Dr. Raymund Buhmann (Leipzig/ DE), Sirak Petros (Leipzig/ DE), Prof. Dr. Reinhard Henschler (Leipzig/ DE)
Background
Therapeutic plasma exchange (TPE) provides evidence-based clinical benefit in a variety of disorders (American Society for Apheresis, DOI: 10.1002/jca.21705). As exchange medium, recommendations reserve fresh frozen plasma for thrombotic thrombocytopenic purpura or to replace clotting factors (e.g. JPAC, United Kingdom; DGTI Section Preparative and Therapeutic Hemapheresis, Germany). Since clear rules are lacking, we initiated a protocol for standardized selection of exchange media in TPE.
Methods
Patients are categorized into a total of five groups as to liver status, fibrinogen (Fg) levels before TPE and recent (24h) bleeding (see figure 1). Principally, 100% Albumin+crystalline solution is used if Fg is > 1.5 g/l in patients with healthy liver. In patients with liver cirrhosis and if Fg is 1.5-2 g/l with no bleeding events <24h, 50%/50% FFP/Albumin or 100% Albumin plus 2g Fg post TPE i.v. are used. If bleeding is recorded the last 24h or if Fg is <1.5 g/l, 100% GFP is used. Bleeding is assessed according to in-house standards and SOPs.
Results
We treated a cohort of 26 patients with the following indications for TPE: acute autoimmune exacerbation (n=13), acute liver failure (n=7), suspected or confirmed TTP (n=3), imminent transplant rejection (n=2) and pretransplant conditioning (n=1), representing a total of 132 TPE procedures. The selection procedure for exchange media was applicable throughout and protocol adherence was nearly complete. No increased bleeding tendency or bleeding complications were observed in the patients. Preliminary data show a significantly lower consumption of donor plasma compared to historical controls. Further analysis in currently ongoing including the number of transfusion incidents, and will be further substantiated by ongoing TPEs.
Conclusion
Our protocol proved feasable and represents a novel instrument to standardize the use of colloids vs FFP in patients undergoing TPE procedures. It is expected to reduce transfusion incidents and immune sensitizations, without exposing patients to additional risks of bleeding complications. Further benefits lie in the preservation of donor plasma, which is a limited source for production of fractionation-derived products. Finally, it should be cost-effective.
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