THERAPEUTIC PLASMA EXCHANGE OUR EXPERIENCE AT SALEM
Dr. Aswin Kumar. SII year M.D., Immunohematology & Blood Transfusion
Vinayaka Mission Medical College, Salem
INTRODUCTION
• APHERESIS, The Greek word ‘Pheresis’ meaning “to take away,” involves the selective removal of blood constituents from donors or patients.
Desired components
Red blood
cell
Platelets Plasma
Whole blood
INTRODUCTION
Therapeutic plasma exchange (TPE),is anextracorporeal blood purification technique used to remove large molecular weight substance like
1. Pathogenic autoantibodies (e.g. Myasthenia Gravis: autoantibody)
2. Cryoglobulins or other abnormal plasma proteins (e.g. Waldenstorm's macroglobulinemia)
3. Immune complexes (e.g. Goodpasture's syndrome)
INDICATIONS
Approximately 300,000 plasma exchange procedures are performed worldwide for various indications like
• Neurological - GBS,MG
• Renal -Good pasture syndrome
• Hematological-TTP, Sickle cell crisis
• Dermatology –Pemphigus vulgaris
• Toxins-Amanita phalloids, OPC
OUR EXPERIENCE
• We started TPE in Jan 2011 till date we have done 110 procedures on 36 patients
Paraquat poisonig
Guillain Barre Syndrome
Myasthenia gravis
Motor neuron disease
Parainfectious demyelinat -ing polyneuropathy
18 Patients12 patients
4 patients1 1
Total no of patients : 36
CASE DISTRIBUTION
DIAGNOSIS No of PatientsCategory of Indication
(AABB/ASFA)
Number of procedure per
patientTotal procedures
Guillain barre syndrome
12 I 5 60
Myasthenia gravis
4 I 5 20
Motor neuron disease
1 I 5 5
Parainfectious demyelinating
spondyloarthropathy
1 I 5 5
Paraquat poisoning
18 III 1 20
AGE DISTRIBUTION
0 - 20 years20 - 40 years
40 - 60 years60 - 80 years
16
11
4
5
4
GENDER DISTRIBUTION
Male; 19Female; 17
Total patients = 36
PROCEDURE
• Instrumentation : Hemonitics cell separator (MCS+)
• Done at : ICU under the supervision of emergency physician
• IV access : Central venous catheter (femoral or internal jugular vein)
• Anticoagulant : Acid citrate dextrose (ACD) anticoagulant is used in 1:16 ratio
KEEP AN EYE ON
• Pulse• Blood pressure • Urine output• Blood flow• Signs of citrate toxicity
VOLUME OF PLASMA EXCHANGE
Formula: The volume of plasma to be exchanged is
determined by patients estimated plasma volume (EPV) and hematocrit (hct)
EPV = 0.07 x weight(kg) X (1-hct) in liters
PLASMA VOLUME EXCHANGE
Plasma Volume Exchange
Percent Removed
0 0%0.5 39.3%1.0 63.2%1.5 77.7%2.0 86.5%2.5 91.8%3.0 95.0%
Efficiency of removal is greatest early in the procedure and diminishes progressively during the exchange.
NUMBER OF PROCEDURES
• Neuro-immunological cases Approximately 5 procedures were
done on alternate days
• Paraquat poisoning Single large volume exchange (1-1.5
plasma volume exchange)
•1 •2 •3 4 5
REPLACEMENT FLUIDS
REPLACEMENT FLUIDS
• Fresh frozen plasma (30 – 40%)
• Colloids(6% hydroxyethyl starch) (30%)
• Crystalloids (30%)
ADVERSE REACTIONS
No adverse reactionsAdverse reactions
0
5
10
15
20
25
30
27
9
Total cases - 36
27
9
ADVERSE REACTIONS
HypotensionFever and chillsCatheter pluggingCitrate toxicity
3 patients2 patients
2 patients
1 patient
SIGNS OF RECOVERY
In Neuro-immnological cases recovery is assessed by
• Recovery from assisted ventilator support• Improvement in muscle power and early
mobilization
CLINICAL DATA
neuro-immunological Paraquat Poisoning
18 18
1112
76
Total cases Mech.Ventilation spontaneous respiration
NEURO-IMMUNOLOGICAL MORTALITY
Total number of Patients - 18Recovered Mortality
Cause of death Respiratory failure
17 patients
1 patient
MORTALITY IN PARAQUAT POISONING
survivors56%
Non survivors44%
Total case : 18
10 patients8 patients
CONCLUSION
The efficacy of plasma exchange in various clinical indications are categorized as follows
Category I – Standard acceptable therapyCategory II – Sufficient evidence to suggest
efficacy usually as adjunctive therapy Category III – inconclusive evidence of efficacy or
uncertain risk/benefit ratio Category IV – Lack of efficacy in controlled trials
CATEGORY - I INDICATIONS(first line therapy )
Neurological:• Guillain Barre synd• Myasthenia Gravis• CIDP• Demyelinating polyneuropathy
with IgG & IgA
Hematological:• TTP• Sickle cell crisis• ABO mismatch Marrow
transplant• Cryoglobinemia
Others:• Cutaneous T cell
Lymphoma• Good pasteur synd• Hypercholestrolemia• Phytanic acid storage
disease• Amanita phalloides
poisoning
CATEGORY - II INDICATIONS
Neurological:
• Lambert -Eaton synd• Acute CNS inflamatory
demyelinating disease• Sydenham’s chorea• PANDAS• Refsum’s diseases
Hematological:
• ITP• Maternal-fetal Rh
incompatability• Coagulation factors inhibitors
Renal & Others:
• RPGN• Acute renal failure due
to cast nephropathy• Graves disease• Digitalis toxicity• Pemphigus vulgaris• Bullous pemphigoid• Toxic epidermonecrolysis
CONCLUSION
• TPEs are successfully performed worldwide but implementation of plasma exchange in our country is still lacking
• The risks and complications associated with this procedure are minimal and manageable
• Utilization of this procedure in large scale will prove beneficiary to patients
CONCLUSION
Therapeutic plasma exchange is• Safe• Cost effective and • Efficacious when performed with expertise in appropriate
indications
TPE
Thank you