Outcomes Following ABO-Incompatible Kidney Transplantation Performed After Desensitization by Nonantigen-Specific Immunoadsorption.

BACKGROUND: For desensitization of ABO-incompatible kidney transplant recipients we recently proposed nonantigen-specific immunoadsorption (IA) and rituximab. METHODS: We now compared clinical outcomes of 34 ABO-incompatible living-donor kidney recipients who were transplanted using this protocol with that of 68 matched ABO-compatible patients. In addition, we analyzed efficacy and cost of nonantigen-specific as compared to blood group antigen-specific IA. RESULTS: Before desensitization, the median isoagglutinin titer of 34 ABO-incompatible patients was 1:64 (Coombs technique). Patients received a median of 7 preoperative IA treatments. Twenty-four patients had a median of 2 additional plasmapheresis treatments to reach the preoperative target isoagglutinin titer of 1:8 or less. After a median postoperative follow-up of 22 months, overall graft survival in the ABO-incompatible group was not significantly different from that in ABO-compatible patients (log-rank P = 0.20), whereas patient survival tended to be lower (log-rank P = 0.05). The incidence of rejection episodes was 15% in both groups. The ABO-incompatible kidney recipients had a higher incidence of BK virus replication (P = 0.04) and nephropathy (P = 0.01) and showed more often colonization with multidrug resistant bacteria (P = 0.02). In comparison to blood group antigen-specific IA, nonantigen-specific IA showed equal efficacy but was associated with reduction in cost. CONCLUSIONS: Clinical outcomes of ABO-incompatible patients desensitized with a nonantigen-specific IA device and rituximab do not differ from that of matched ABO-compatible patients although a trend toward reduced patient survival was noted. Special attention must be paid to the higher incidence of BK virus infection in recipients of ABO-incompatible grafts.

Comparative analysis of therapeutic options used for myasthenia gravis.

OBJECTIVE: To compare clinical and economic outcomes following plasma exchange (PLEX) and intravenous immunoglobulin (IVIG) in U.S. patients with primary diagnoses of myasthenia gravis (MG). METHODS: Our cohort was identified from the Nationwide Inpatient Sample database for years 2000-2005 using codes from the International Classification of Diseases, 9th edition. Multivariate regression analyses were used to identify predictors of mortality, complications, length of stay, and total inpatient cost. RESULTS: Among 1,606 hospitalized patients, the unadjusted mortality rate of MG crisis remained higher than those without crisis (0.44% vs 4.44%, p < 0.001), as well as the unadjusted complication rate (26.36% vs 11.23%, p < 0.001). MG crisis patients receiving PLEX had significantly more complications than those receiving IVIG (30.06% vs 14.79%, p < 0.001). Among the whole cohort, adjusted mortality and complication rates were not significantly different between the treatment groups (p > 0.05). Acute respiratory failure, major cardiac complications, and acute renal failure were associated with an increased mortality rate (p < 0.001). Age and respiratory failure were associated with an increased complication rate (p < 0.001). Length of stay was significantly longer for MG (6 vs 4 days, p < 0.001) and MG crisis (10 vs 5 days, p < 0.001) patients receiving PLEX. Inpatient costs were higher for MG ($26,662 vs $21,124, p < 0.01) and MG crisis ($53,801 vs $33,924, p < 0.001) patients receiving PLEX. INTERPRETATION: Compared to PLEX, IVIG appears of similar clinical (mortality and complications) and perhaps of superior economic (length of stay and total inpatient charges) outcomes in the treatment of MG. Elderly and those with complex comorbid diseases including acute respiratory failure may be better treated with IVIG.

[Cost analysis of autologous transfusion methods--a study of 5,017 patients]. / Kostenanalyse autologer Transfusionsverfahren--eine Untersuchung bei 5017 Patienten.

PURPOSE: Cost analysis of autologous blood conservation measures compared to corresponding homologous blood products. METHODS: This study is based on data from 5,017 patients undergoing major bone and joint surgery in 1993 and participating preoperatively in autologous blood donation (ABD) (with hemoseparation (HS) into autologous packed red blood cells (APRBC) and autologous fresh-frozen-plasma (AFFP)), autologous plasmapheresis (APPH) for harvesting AFFP as well as intra-/postoperative blood salvage with mechanically processed autologous transfusion (MAT). RESULTS: Total costs for 3,110 ABD with HS amount to DM 517,586.00 resulting in about DM 167.00 per U of APRBC plus AFFP. Comparatively, costs per U of HPRBC is about DM 202.00. Break-even-point (BEP) is calculated with 2,258 U of APRBC (without considering AFFP additionally obtained by HS). Taking into account this AFFP due to coagulation in 20% lowers BEP to 1,819 U of APRBC. However, this analysis compares the "mere" cost figures only, but does not consider the extent of ABD-induced increase in rbc mass compared to that of HPRBC. Under these circumstances calculated cost per unit of APRBC is up to 90 per cent higher than for 1 U of HPRBC. Total cost for PPH with 15,570 U of AFFP amounts to about DM 1,824,162.00, resulting in about DM 115.00 per U of AFFP. Comparatively, cost per U of HFFP is about DM 136.00. BEP is calculated with 11,595 U of AFFP. However, when considering AFFP on coagulatory reasons' with 20% only, no BEP can be calculated and AFFP is not proven to be cost-efficient. Under these conditions it is about 2.8-times more expensive than HFFP; and if considering AFFP a volume substitute it is even more than twelve times more expensive than artificial colloids (e.g. HES 6%, 200/0.5). MAT--2,690 sets and patients with a total of 5,326 processing cycles--causes a total cost of about DM 1,356,161.00, resulting in about DM 504.00 per set and patient. Under our conditions MAT is not cost-efficient compared to HPRBC as it is about two times more expensive than HPRBC. For reaching cost efficiency the number of processing cycles is either to be increased from about 2 to about 4 cycles per set and patient or hematocrit of the rbc-product obtained by MAT is clearly to be increased. CONCLUSIONS: The "mere" figures of this cost analysis of APRBC versus HPRBC as well as of AFFP versus HFFP and HES appear in favour of the autologous products. However, such an analysis should consider--besides the costs--both the increase in rbc-mass obtained by ABD or MAT, versus homologous rbc, and the indication for administering AFFP. This study does not prove our autologous blood conservation measures to be cost efficient compared to homologous blood products. Therefore, these data may cause a critically reflection on established concepts of autologous transfusion measures and may initiate promoting new and more cost efficient constellations/alternatives of blood conservation measures.

Platelet-rich plasmapheresis: a meta-analysis of clinical outcomes and costs.

Platelet-rich plasmapheresis (PRP) just prior to cardiopulmonary bypass (CPB) surgery is used to improve post CPB hemostasis and to minimize the risks associated with exposure to allogeneic blood and its components. Meta-analysis examines evidence of PRP's impact on clinical outcomes by integrating the results across published research studies. Data on clinical outcomes was collected from 20 published studies. These outcomes, DRG payment rates, and current national average costs were used to examine the impact of PRP on costs. This study provides evidence that the use of PRP results in improved clinical outcomes when compared to the identical control groups not receiving PRP. These improved clinical outcomes result in subsequent lower costs per patient in the PRP groups. All clinical outcomes analyzed were improved: blood product usage, length of stay, intensive care stay, time to extubation, incidence of cardiovascular accident, and incidence of reoperation. The most striking differences occur in use of all blood products, particularly packed red blood cells. This study provides an example of how initial expenditure on technology used during CPB results in overall cost savings. Estimated cost savings range from $2,505.00 to $4,209.00. More importantly, patients benefit from improved clinical outcomes.

Passive hyperimmune therapy: buying time at what cost?

Some AIDS physicians are now turning to passive hyperimmune therapy as an alternative to try to protect and rebuild AIDS patients' ravaged immune systems. This is a labor-intensive and expensive treatment that raises many questions.

Practice of autologous preoperative plasmapheresis in Germany in 1993.

Autologous preoperative plasmapheresis which is being performed at the University Hospital of Tübingen since 1984 in advance of surgical, orthopaedic or gynecologic operations, constitutes, in combination with intraoperative autotransfusion (IAT), an optimal method to compensate high losses of intravascular volume. Unlike all other procedures which also substitute lost volume (such as infusion of electrolytic solutions or plasma expanders, haemodilution, retransfusion of preoperatively donated autologous blood, transfusion of homologous plasma or foreign blood) this method grants optimal clotting as well as intravascular retention of volume and in addition to this excludes every risk of infection. Although the therapeutic advantages of autologous preoperative plasmapheresis are well known and confirmed by our statistics (about 75% of the patients do not need any foreign blood), the method is rarely practiced in Germany and mainly performed in specialized hospitals (e.g. in the orthopaedic departments of Tübingen, Ulm, Hamburg, Hannover or Essen). This unfortunate situation is obviously due to some of the following, primarily logistic problems. First of all the procedure of autologous preoperative plasmapheresis needs relatively long planning in advance of the operation (between 2 and 4 weeks) and a number of surgeons renounces the method--even if the patient's medical condition is appropriate and no higher costs are to be expected. The above mentioned alternatives of compensating blood losses are preferred, even if they are in no way comparable in their efficiency. Secondly, in Germany autologous preoperative plasmapheresis is mostly performed by an anaesthetist, who is, however, under our laws obliged to reinfuse the plasma himself, which he has taken from a patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of filtration to continuous-flow centrifugation for plasma exchange.

The Asahi Plasmaflo Hollow Nylon Fibre Filtration System (n = 13) was directly compared to the NCI-IBM 2990 Continuous-Flow Blood Fraction Separator (n = 10) for plasma exchange. The systems were equally efficient in achieving plasma separation. There were significant differences favouring filtration for clearance of fibrinogen (P less than 0.05), and the fourth component of complement (P less than 0.01). Greater loss of urea (P less than 0.05) was found after plasma exchange, using the cell separator. The flow characteristics were markedly different. In a standardised 4-L plasma exchange, filtration took place at 35 ml/minute, with a procedure time of 109 +/- 45 minutes in contrast to centrifugation at a plasma flow collection rate of 19 ml/minute, requiring 208 +/- 17 minutes. This time advantage for the former procedure was offset by 195 minutes required to regenerate the hollow nylon fibre unit and a further 90 minutes required for cleaning under strictly controlled aseptic techniques prior to reuse. Each filter was regenerated at least twice and reused without infection, but there was incremental loss of filtration efficiency demonstrated by decreasing clearance of an intravascular marker dye. In two of the 13 procedures using the Plasmaflo system, serious reactions necessitated termination of the procedure; this did not occur using the cell separator. Restriction of the number of times that the filter unit could be regenerated without loss of efficiency, the prolonged time required for regeneration and cleaning, coupled with the need for artificial vascular access to meet high blood flow rates required, limit the usefulness of this technique for plasma exchange.

Impact of factor VIII deficiency on clotting factor utilization in the United States.

In a study of 1,551 hemophiliacs over a 4-year period of time, factor VIII utilization was assessed. It is clear that factor VIII usage is a function of severity of disease and therapeutic program. The average amount of factor VIII used per patient was 39,880 U/year. Patients selected for home care, use significantly more than those patients not on home care. As much as 101,000 U/year are used by a small number of patients on prophylaxis. These data can be used in predicting source plasma requirements for annual national use as well as costs.