The Effect of Transfusion of Two Units of Fresh Frozen Plasma on the Perioperative Fibrinogen Levels and the Outcome of Patients Undergoing Elective Endovascular Repair for Abdominal Aortic Aneurysm.

BACKGROUND: We aimed to investigate whether the transfusion of 2 units of fresh frozen plasma (FFP) immediately post aneurysm exclusion has any effect on the perioperative fibrinogen levels and the outcome of patients undergoing elective endovascular repair (EVAR) of abdominal aortic aneurysm (AAA). METHODS: Consecutive infrarenal AAA patients undergoing elective EVAR with the bifurcated Endurant-II stent-graft (Medtronic) were recruited from 2 vascular units. The first unit has a routine policy of administering 2 units of FFP immediately upon aneurysm exclusion (FFP group), whereas the second unit has no such policy (control group). Serum fibrinogen levels were measured on admission and 24 hr post-EVAR and the perioperative change in fibrinogen (Δfib) was calculated (24-hr postoperative minus preoperative fibrinogen). The 2 groups were compared with regards to the perioperative fibrinogen levels (preoperative, 24-hr postoperative, and Δfib) and the outcome (endoleaks, reinterventions, major adverse cardiovascular events, death) during follow up. RESULTS: A total of 70 patients (41 in the FFP group, 29 controls) were examined. There were 68 men, the mean age was 70 ± 7 years and the maximum AAA diameter was 63.3 ± 13.8 mm. During the follow up (34 ± 19 months), a total of 6 endoleaks were recorded (2 type Ia, 2 type Ib and 1 type II). Mean preoperative fibrinogen, 24-hr postoperative fibrinogen and Δfib was 391.1 ± 92.8 mg/dL, 367.7 ± 97.8 mg/dL and -23.5 ± 51.02 mg/dL, respectively. There was a trend for the fibrinogen to fall 24 hr postprocedure, but this was not statistically significant (P = 0.07). There was a weak negative association between Δfib and endoleaks (P = 0.007, r = -0.29). Compared to controls, the FFP group had a higher 24-hr postoperative fibrinogen (401.8 ± 112.9 mg/dL vs. 319.3 ± 34.9 mg/dL, P < 0.0001) and a lower Δfib (-3.00 ± 56.01 mg/dL vs. -52.48 ± 21.15 mg/dL, P < 0.0001). No significant difference was observed between the 2 groups with regards to endoleaks, reinterventions, major adverse cardiovascular events, or deaths. CONCLUSIONS: Transfusion of 2 units of FFP postaneurysm exclusion prevents a significant drop in plasma fibrinogen 24 hr post-EVAR, but the impact on clinical outcome has yet to be defined.

Effect of artificial liver blood purification treatment on the survival of critical ill COVID-19 patients.

Our aim was to investigate the effect of artificial liver blood purification treatment on the survival of severe/critical patients with coronavirus disease 2019 (COVID-19). A total of 101 severe and critical patients with coronavirus SARS-CoV-2 infection were enrolled in this open, case-control, multicenter, prospective study. According to the patients' and their families' willingness, they were divided into two groups. One was named the treatment group, in which the patients received artificial liver therapy plus comprehensive treatment (n = 50), while the other was named the control group, in which the patients received only comprehensive treatment (n = 51). Clinical data and laboratory examinations, as well as the 28-day mortality rate, were collected and analyzed. Baseline data comparisons on average age, sex, pre-treatment morbidity, initial symptoms, vital signs, pneumonia severity index score, blood routine examination and biochemistry indices etc. showed no difference between the two groups. Cytokine storm was detected, with a significant increase of serum interleukin-6 (IL-6) level. The serum IL-6 level decreased from 119.94 to 20.49 pg/mL in the treatment group and increased from 40.42 to 50.81 pg/mL in the control group (P < .05), indicating that artificial liver therapy significantly decreased serum IL-6. The median duration of viral nucleic acid persistence was 19 days in the treatment group (ranging from 6 to 67 days) and 17 days in the control group (ranging from 3 to 68 days), no significant difference was observed (P = .36). As of 28-day follow-up,17 patients in the treatment group experienced a median weaning time of 24 days, while 11 patients in the control group experienced a median weaning time of 35 days, with no significant difference between the two groups (P = .33). The 28-day mortality rates were 16% (8/50) in the treatment group and 50.98% (26/51) in the control group, with a significant difference (z = 3.70, P < .001). Cytokine storm is a key factor in the intensification of COVID-19 pneumonia. The artificial liver therapy blocks the cytokine storm by clearing inflammatory mediators, thus preventing severe cases from progressing to critically ill stages and markedly reducing short-term mortality.

Deaths and complications associated with the management of acute immune thrombotic thrombocytopenic purpura.

BACKGROUND: The introduction of therapeutic plasma exchange (TPE) dramatically decreased mortality in patients with immune thrombotic thrombocytopenic purpura (iTTP). However, there are few modern descriptions of residual causes of death from iTTP and complications associated with TPE. STUDY DESIGN AND METHODS: This was a retrospective study in a multi-institutional cohort of 109 patients with iTTP between 2004 and 2017. Complications of TPE were analyzed in a subset of this cohort (74 patients representing 101 treatment courses). RESULTS: Death occurred in 8 of 109 patients (7.3%) and in 8 of 219 captured episodes of acute iTTP (mortality rate per episode: 3.7%). Neither the number of TPE treatments nor length of hospitalization predicted mortality. The majority of deaths (5/8) were associated with delay in the diagnosis of iTTP or initiation of TPE or presentation to the hospital in a moribund state. A subset of patients (N = 74) was analyzed for TPE-related complications. Most patients (56/74; 76%) had at least one minor or major complication of TPE. Seven of 101 (6.9%) discrete treatment courses were associated with one or more severe complications, including anaphylaxis and line-associated infections and thrombosis. Overall, the most frequent adverse events were mild allergic (urticarial) transfusion reactions, which affected 34 of 101 (34%) treatment courses. One patient died from a TPE-related complication, line-associated bacteremia. CONCLUSION: Early identification of patients with iTTP and the rapid initiation of TPE are paramount in preventing mortality. While TPE was associated with a high rate of adverse events, the vast majority were treatable and TPE-related mortality is low.

Predictors of In-Hospital Mortality in Thrombotic Thrombocytopenic Purpura in Children in the United States: A Population Analysis.

BACKGROUND: Despite proven efficacy and increased availability of therapeutic plasma exchange, thrombotic thrombocytopenic purpura (TTP) is associated with significant morbidity and mortality. STUDY DESIGN AND METHODS: This study utilized the Kids' Inpatient Database and National Inpatient Sample (2003 to 2016) to study predictors of in-hospital mortality in hospitalized TTP patients. Adjusted odds ratios of death with various putative risk factors were calculated using multiple regression analysis. RESULTS: Among 1568 hospitalizations with TTP as primary admission diagnosis who underwent therapeutic plasma exchange, 69 deaths were identified (all-cause mortality, 0.04%; median time-to-death, 6 wk). Overall, hospitalizations rates were fairly similar across the study period. The overall incidence of TTP related hospitalizations is 1.51 per 100,000 hospitalizations. A total of 69 deaths were reported with an all-cause in-hospital mortality rate of 0.04% (69/1568). The median time-to-death was 6 weeks. The majority of deaths occurred in age 16 to 20 years (58%), females (56.5%), and African American (42.9%) as shown in Table 2. Mean age for nonsurvivors was 14 years and the mean age of 15 years for survivors (P=0.01). Younger age, male sex, African-American ethnicity, malignancy, sepsis, acute kidney injury, platelet transfusion was significantly associated with mortality in patients with TTP. CONCLUSIONS: Early and targeted therapy for high risk individuals should be used to guide management of TTP patients for improved survival outcomes.

Indications for and outcomes of therapeutic plasma exchange after cardiac transplantation: A single center retrospective study.

INTRODUCTION: Limited data are available describing indications for and outcomes of therapeutic plasma exchange (TPE) in cardiac transplantation. METHODS: In a retrospective study of patients who underwent cardiac transplantation at Duke University Medical Center from 2010 to 2014, we reviewed 3 TPE treatment patterns: a Single TPE procedure within 24 h of transplant; Multiple TPE procedures initiated within 24 h of transplant; and 1 or more TPE procedures beginning >24 h post-transplant. Primary and secondary outcomes were overall survival (OS) and TPE survival (TS), respectively. RESULTS: Of 313 patients meeting study criteria, 109 (35%) underwent TPE. TPE was initiated in 82 patients within 24 h, 40 (37%) receiving a single procedure (Single TPE), and 42 (38%) multiple procedures (Multiple TPE). Twenty-seven (25%) began TPE >24 h after transplant (Delayed TPE). The most common TPE indication was elevated/positive panel reactive or human leukocyte antigen antibodies (32%). With a median follow-up of 49 months, the non-TPE treated and Single TPE cohorts had similar OS (HR 1.08 [CI, 0.54, 2.14], P = .84), while the Multiple and Delayed TPE cohorts had worse OS (HR 2.62 [CI, 1.53, 4.49] and HR 1.98 [CI, 1.02, 3.83], respectively). The Multiple and Delayed TPE cohorts also had worse TS (HR 2.59 [CI, 1.31, 5.14] and HR 3.18 [CI, 1.56, 6.50], respectively). Infection rates did not differ between groups but was independently associated with OS (HR 2.31 [CI, 1.50, 3.54]). CONCLUSIONS: TPE is an important therapeutic modality in cardiac transplant patients. Prospective studies are needed to better define TPE's different roles in this patient population.

Effects of therapeutic plasma exchange on early allograft dysfunction after liver transplantation.

BACKGROUND: Early allograft dysfunction (EAD) is a serious complication of liver transplantation (LT) and is associated with graft failure, which can result in patient mortality. Due to the shortage of organs for retransplantation, only a small proportion of EAD patients undergo retransplantation. Thus, liver support is needed for most patients with EAD. METHODS: We evaluated the effects of therapeutic plasma exchange (TPE) in EAD patients. EAD was defined as a sustained hyperbilirubinemia (≥10 mg/dL) within 30 days of LT without concurrent biliary complications. In a 13-year period, 107 EAD patients underwent TPE while 36 EAD patients did not. We investigated the laboratory and clinical outcomes of TPE and non-TPE groups. RESULTS: The TPE group showed 1-month and 1-year survival rates of 82.2% and 53.8%, respectively, whereas the non-TPE group showed 58.3% and 22.2%, respectively. In TPE group, statistically significant decreases (P < 0.05) in total bilirubin (15.2 ± 5.2 to 13.1 ± 5.4 mg/dL), and INR (1.72 ± 1.04 to 1.38 ± 1.14), were seen after the final TPE session. TPE responder groups with age <51 years, total bilirubin <11.1 mg/dL, or INR <1.15 after final TPE showed better prognosis. TPE decreased the hazard risk of death in EAD patients whereas older age, male gender, and higher INR on the day of EAD onset increased the risk. CONCLUSIONS: TPE effectively removed plasma bilirubin and improved coagulation function in EAD patients, with higher survival in the TPE group than in the non-TPE group. TPE may be an effective liver support for EAD patients. J. Clin. Apheresis 32:147-153, 2017. © 2016 Wiley Periodicals, Inc.

Prognostic risk-stratified score for predicting mortality in hospitalized patients with thrombotic thrombocytopenic purpura: nationally representative data from 2007 to 2012.

BACKGROUND: Despite proven efficacy and increased availability of therapeutic plasma exchange (TPE), mortality for patients with thrombotic thrombocytopenic purpura (TTP) remains high with a limited understanding of those at highest risk of death. STUDY DESIGN AND METHODS: This study utilized the Nationwide Inpatient Sample (2007-2012) to derive a prognostic score for mortality in hospitalized TTP patients. Odds ratios of death with various putative risk factors adjusted for age, sex, and race were calculated (adjOR). Weighted mean of adjOR estimates were incorporated in a risk-stratified score. RESULTS: Among 8203 hospitalizations with TTP as primary admission diagnosis who underwent TPE, 613 deaths were identified (all-cause mortality, 7.5%; median time-to-death, 9 days; interquartile range, 4-14 days). In multivariable logistic regression, arterial thrombosis (adjOR 6.7, 95% confidence interval [CI], 1.1-40.9), intracranial hemorrhage (adjOR, 6.1; 95% CI, 1.6-23.2), age at least 60 years (adjOR, 3.5; 95% CI, 2.1-5.6), renal failure (adjOR, 2.6; 95% CI, 1.5-4.5), ischemic stroke (adjOR, 2.4; 95% CI, 1.2-5.0), platelet (PLT) transfusions (adjOR, 2.2; 95% CI, 1.2-4.1), and myocardial infarction (adjOR, 2.3; 95% CI, 1.2-4.6) were significant independent predictors of mortality in TTP patients who underwent TPE. A prognostic weighted mortality prediction scoring system incorporating arterial thrombosis, intracranial hemorrhage, age, renal failure, ischemic stroke, PLT transfusion, and myocardial infarction showed very good discrimination and was predictive of 78.6% deaths. CONCLUSIONS: Early and targeted therapy for high-risk individuals should be used to guide management of TTP patients for improved survival outcomes.

Plasma exchange-centered artificial liver support system in hepatitis B virus-related acute-on-chronic liver failure: a nationwide prospective multicenter study in China.

BACKGROUND: Plasma exchange (PE)-centered artificial liver support system reduced the high mortality rate of hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF). But the data were diverse in different medical centers. The present prospective nationwide study was to evaluate the effects of PE on patients with HBV-ACLF at different stages. METHODS: From December 2009 to December 2011, we evaluated 250 patients at different stages of HBV-ACLF from 10 major medical centers in China. All the laboratory parameters were collected at admission, before and after PE. RESULTS: Among the 250 patients who underwent 661 rounds of PE, one-month survival rate was 61.6%; 141 (56.4%) showed improvement after PE. Variables such as age (P=0.000), levels of total bilirubin (TB, P=0.000), direct bilirubin (P=0.000), total triglycerides (P=0.000), low-density lipoprotein (P=0.022), Na+ (P=0.014), Cl- (P=0.038), creatinine (Cr, P=0.007), fibrinogen (P=0.000), prothrombin time (PT, P=0.000), white blood cell (P=0.000), platelet (P=0.003) and MELD (P=0.000) were significantly related to prognosis. Multivariate logistic regression analysis showed that age, disease stage, TB, Cr and PT levels were independent risk factors of mortality among HBV-ACLF patients. CONCLUSIONS: PE can improve the clinical outcome of patients with HBV-ACLF. Levels of TB, Cr and PT, age and disease stage help to predict prognosis.

Characterization of the complications associated with plasma exchange for thrombotic thrombocytopaenic purpura and related thrombotic microangiopathic anaemias: a single institution experience.

BACKGROUND: Plasma exchange (PEX) is a life-saving therapeutic procedure in patients with thrombotic thrombocytopaenic purpura (TTP) and other thrombotic microangiopathic anaemias (TMAs). However, it may be associated with significant complications, exacerbating the morbidity and mortality in this patient group. STUDY DESIGN AND METHODS: We reviewed all PEX procedures over a 72-month period, following the exclusive introduction of solvent-detergent double viral-inactivated plasma in high-volume users, such as TTP, in the United Kingdom (UK). We documented allergic reactions to plasma, citrate reactions, complications relating to central venous access insertion and venous thrombotic events (VTE) in 155 patient episodes and >2000 PEX procedures. RESULTS: The overall complication rate was low. Allergic plasma reactions occurred in 6·45% of the cohort with only one episode of acute anaphylaxis. Similarly, VTEs were 6·45%, not significantly greater than in medical patients receiving thromboprophylaxis, despite added potential risk factors in TTP. Citrate reactions were the most frequent complication documented, but toxicity was significantly reduced by administration of further calcium infusions during the PEX procedure. There were no serious central line infections and no catheter thrombosis. CONCLUSION: Our data confirms that PEX continues to be a life-saving procedure in the acute TTP setting and, the procedure was not associated with an increased mortality and limited morbidity.

The efficacy and safety of plasma exchange in patients with sepsis and septic shock: a systematic review and meta-analysis.

INTRODUCTION: Sepsis and septic shock are leading causes of intensive care unit (ICU) mortality. They are characterized by excessive inflammation, upregulation of procoagulant proteins and depletion of natural anticoagulants. Plasma exchange has the potential to improve survival in sepsis by removing inflammatory cytokines and restoring deficient plasma proteins. The objective of this study is to evaluate the efficacy and safety of plasma exchange in patients with sepsis. METHODS: We searched MEDLINE, EMBASE, CENTRAL, Scopus, reference lists of relevant articles, and grey literature for relevant citations. We included randomized controlled trials comparing plasma exchange or plasma filtration with usual care in critically ill patients with sepsis or septic shock. Two reviewers independently identified trials, extracted trial-level data and performed risk of bias assessments using the Cochrane Risk of Bias tool. The primary outcome was all-cause mortality reported at longest follow-up. Meta-analysis was performed using a random-effects model. RESULTS: Of 1,957 records identified, we included four unique trials enrolling a total of 194 patients (one enrolling adults only, two enrolling children only, one enrolling adults and children). The mean age of adult patients ranged from 38 to 53 years (n = 128) and the mean age of children ranged from 0.9 to 18 years (n = 66). All trials were at unclear to high risk of bias. The use of plasma exchange was not associated with a significant reduction in all-cause mortality (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.45 to 1.52, I(2) 60%). In adults, plasma exchange was associated with reduced mortality (RR 0.63, 95% CI 0.42 to 0.96; I(2) 0%), but was not in children (RR 0.96, 95% CI 0.28 to 3.38; I(2) 60%). None of the trials reported ICU or hospital lengths of stay. Only one trial reported adverse events associated with plasma exchange including six episodes of hypotension and one allergic reaction to fresh frozen plasma. CONCLUSIONS: Insufficient evidence exists to recommend plasma exchange as an adjunctive therapy for patients with sepsis or septic shock. Rigorous randomized controlled trials evaluating clinically relevant patient-centered outcomes are required to evaluate the impact of plasma exchange in this condition.

Long-term follow-up of patients with severe ANCA-associated vasculitis comparing plasma exchange to intravenous methylprednisolone treatment is unclear.

Patients with antineutrophil cytoplasm antibody-associated vasculitis (AAV) requiring dialysis at diagnosis are at risk for developing end-stage renal disease (ESRD) or dying. Short-term results of a trial comparing plasma exchange (PLEX) to intravenous methylprednisolone (IV MeP) suggested PLEX improved renal recovery. Here we conducted long-term follow-up to see if this trend persisted. A total of 137 patients with newly diagnosed AAV and a serum creatinine over 500 µmol/l or requiring dialysis were randomized such that 69 received PLEX and 68 received IV MeP in addition to cyclophosphamide and oral glucocorticoids. The patients were followed for a median of 3.95 years. In each group there were 35 deaths, while 23 PLEX and 33 IV MeP patients developed ESRD. The hazard ratio for PLEX compared to IV MeP for the primary composite outcome of death or ESRD was 0.81 (95% confidence interval 0.53-1.23). The hazard ratio for all-cause death was 1.08 with a subhazard ratio for ESRD of 0.64 (95% confidence interval 0.40-1.05). Thus, although short-term results with PLEX are encouraging, the long-term benefits remain unclear. Further research is required to determine the role of PLEX in AAV. Given the poor outcomes of patients with severe AAV, improved treatment is urgently needed.

Decreasing frequency of plasma exchange complications in patients treated for thrombotic thrombocytopenic purpura-hemolytic uremic syndrome, 1996 to 2011.

BACKGROUND: Plasma exchange (PEX) treatment for patients with thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) has risk for major complications. STUDY DESIGN AND METHODS: Data for PEX-related complications have been prospectively collected on all patients enrolled in the Oklahoma TTP-HUS Registry, 1996 to 2011. PEX-related complications have been defined as major or minor and as central venous catheter related or plasma related. RESULTS: During 15 years, 1996 to 2011, 72 (24%) of 302 consecutive patients had major PEX-related complications. Analysis of five consecutive 3-year cohorts demonstrated that there has been a significant trend for decreasing frequency of all PEX-related major complications (p = 0.014) and central venous catheter-related major complications (p = 0.021) but not for the less common plasma-related major complications (p = 0.380). ADAMTS13 activity was measured in 288 (95%) of the 302 patients. Analysis of the 66 patients with ADAMTS13 activity of less than 10% demonstrated a significant trend for decreasing frequency of PEX-related major complications (p = 0.036); the trend for the 222 patients with ADAMTS13 activity of at least 10% was not significant (p = 0.118). The decreased frequency of PEX-related major complications among patients with ADAMTS13 activity of less than 10% may be related to a significant trend for decreasing duration of PEX treatment (p = 0.040) and decreasing frequency of requirement for more than one central venous catheter (p = 0.044). The decreased duration of PEX treatment may be related to increased use of adjunctive treatments: corticosteroids (p < 0.001) and rituximab (p < 0.001). CONCLUSIONS: The frequency of PEX-related major complications has decreased from 1996 to 2011, possibly related to increased use of corticosteroids and rituximab and the decreased duration of PEX required to achieve remission.

Early plasma exchange improves outcome in PR3-ANCA-positive renal vasculitis.

OBJECTIVES: Plasma exchange (PE) has been shown to improve renal outcome in anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) and severe renal failure; however the effect of PE in AAV with moderate renal impairment is controversial. METHODS: A single-centre, retrospective one-year follow-up study, including patients with renal AAV and eGFR <60 ml/min/1.73 m2. Since 2007, all patients with renal AAV and eGFR <60 ml/min/1.73 m2 had PE in addition to induction therapy with cyclophosphamide and prednisolone. Patients admitted from 1999 to 2007 that did not receive PE served as controls. The primary outcome was the combination of death, end-stage renal disease, and relapses after one year. RESULTS: A significant reduction in the primary endpoint was observed following the addition of PE (25% vs. 43%, p=0.04). Furthermore, a greater improvement in renal function after one year was observed among surviving PE treated patients not on dialysis (ΔeGFR 36.1 vs. 19.7 ml/min, p=0.03). There was a significant reduction in serious adverse events in the PE treated group (4% vs. 30%, p=0.02) despite no differences in types and doses of induction immunosuppressive therapy. The advantageous effect of PE was related to the presence of anti-proteinase3 (PR3)-antibodies and also evident among patients with plasma creatinine less than 500 µM. CONCLUSIONS: This study suggests the use of PE in addition to standard induction treatment with cyclophosphamide and glucocorticoids to patients with renal PR3-AAV and an estimated-GFR <60 ml/min/1.73m2.

Granulocytapheresis and plasma exchange for severe alcoholic hepatitis.

BACKGROUND AND AIM: Severe alcoholic hepatitis (SAH) is an inflammatory response with multiple morbidity factors like leucocytosis, hepatomegaly, renal failure, hepatic encephalopathy, endotoxemia, and a high mortality rate. Identifying therapeutic interventions that can improve prognosis is the goal of research. METHODS: Questionnaires were sent to 1234 medical institutions asking for information on patients with SAH during 2004 to 2008, including patients' demography, disease profile and the therapeutic interventions patients had received during hospitalization. RESULTS: Forty-five hospitals had treated SAH patients, and provided full demographic data on 98 patients. Forty-eight patients had received no treatment, 12 patients had received granulocytes/monocytes apheresis (GMA) to deplete elevated myeloid lineage leucocytes, the rest had received one or more of the following treatments, corticosteroids, plasma exchange (PE) and hemodialysis (HD). Further, 38 patients had died and 60 had survived within 100 days of hospitalization. Serum creatinine (Cr) was higher in patients who had died versus patients who had survived (P = 0.001). Likewise, patients with white blood cells (WBC) ≥ 10(4)/µL had higher mortality rate versus patients with WBC < 10(4)/µL (P = 0.018). GMA in patients with WBC ≥ 10(4)/µL showed improved prognosis versus in patients with WBC ≥ 10(4)/µL who did not receive GMA (P = 0.0006). Corticosteroids, plasma exchange and HD did not significantly impact prognosis of SAH patients. CONCLUSIONS: Our perception is that, patients with elevated myeloid leucocytes benefit most from GMA, while plasma exchange appears to support patients with coagulation deficiency or high plasma bilirubin and HD has indication in patients with high Cr.

Therapeutic plasma exchange in the elderly: experience at a tertiary center.

Therapeutic plasma exchange (TPE) is a beneficial albeit complicated method of therapy. The elderly, persons 65 years or older are growing in number, with increasing need for different therapeutic interventions including TPE. The elderly are more likely to have complications and pose challenges when considering TPE--both in terms of indications and outcomes. We retrospectively investigated the utility of TPE in terms of indications and mortality in the elderly (65 and above) versus a younger cohort (18-64 years) between January 1, 2000 and June 30, 2010. During this period, 581 patients required 4,722 TPE treatment sessions. Of them, 185 were elderly (31.8%) requiring 1,289 TPE sessions. The indications for TPE were neurological 14.1%, hematological 10.5%, renal 6.9%, and miscellaneous 2.0% in the elderly versus 22.7%, 20.8%, 20.7%, and 4.0% in the younger population undergoing TPE for neurological, hematological, renal and miscellaneous indications, respectively. We further investigated the mortality within 30 days of admission and a year later. The mortality figures within 30 days of admission and a year later in the elderly were 16.2% and 33.5%, respectively; higher than in the younger patients; 10.3% and 17.2%, respectively. We conclude that TPE is not an uncommon procedure in elderly, with more neurological indications, and is associated with higher mortality than younger patients.

Outcome and relapse risks of thrombotic thrombocytopaenic purpura: an Egyptian experience.

BACKGROUND: Thrombotic thrombocytopaenic purpura (TTP) is a rare life-threatening disease. Plasma exchange has significantly decreased the mortality from this disease, which still tends to recur in a substantial proportion of patients. This study describes the clinical spectrum and response to treatment and explores the risks of relapse in a cohort of patients. METHODS: Patients treated for TTP at the Clinical Haematology Unit, Cairo University, Egypt, between 2000 and 2008 were identified. Complete demographic, clinical history and full clinical examination, laboratory, treatment modalities and duration, and outcome data were collected and analysed. The follow-up duration was 24 months. RESULTS: 30 patients; 13 men (43%) and 17 women (57%) with a median age of 42 years were treated for 46 episodes of TTP. The median duration of disease onset to diagnosis for the first episode was 7 days. Twenty-three patients (76.66%) were diagnosed as idiopathic primary and seven patients (23.33%) were secondary TTP. Four patients died during the first 24 h. Of the 26 patients, 22 (85.6%) achieved remission with an average of 7.55 plasma exchange sessions, Another nine patients had 25 relapses (mean 2.7). Splenectomy was performed in three patients (11.5%). The 24-month overall survival was 80%. The initial low platelet count and high LDH were the only two statistically significant relapse predictors. CONCLUSIONS: The current results conform to the reported literature on the outcome of TTP. The very early mortality due to late referral highlights the need of education about the disease among primary healthcare providers.

[Treatment of typical hemolytic-uremic syndrome. Knowledge gained from analyses of the 2011 E. coli outbreak]. / Therapie des typischen hämolytisch-urämischen Syndroms. Erkenntnisse aus dem E.-coli-Ausbruch 2011.

Shiga toxin-associated hemolytic uremic syndrome (HUS) is an entity of thrombotic microangiopathy characterized by hemolytic anemia, thrombocytopenia, central nervous symptoms, and renal insufficiency. In May 2011, an outbreak of enterohemorrhagic Escherichia coli (EHEC; O104:H4) occurred in Northern Germany. By the end of July 2011, the outbreak was over but nearly 4000 patients had an EHEC infection, 855 cases of hemolytic-uraemic syndrome were reported to the Robert Koch Institute, and there were 35 (4.1%) deaths. Shiga toxin-induced HUS is a rare disease and no controlled clinical trials on therapeutic options are available. First analyses of this outbreak suggest that therapeutic plasma exchange, which was used in the majority of patients, had no benefit and might even be harmful. The role of eculizumab, a monoclonal antibody which inhibits the complement system, is being examined in a multicenter study: the results have not been published yet. Promising is the use of some antibiotics. This would change a paradigm that antibiotics should be avoided. Ongoing and future analyses of the epidemic should be awaited before a final recommendation regarding the different treatment strategies can be made.

Role of therapeutic plasma exchange in acute liver failure due to yellow phosphorus poisoning.

BACKGROUND: Therapeutic plasma exchange (TPE) has been utilized in various liver disorders. There is limited data on the efficacy of TPE in patients with acute liver failure (ALF). METHODS: Study group consisted of patients who underwent TPE for ALF due to yellow phosphorous poisoning (YPP) between 2015 and 2019. Demographic data and biochemical parameters were recorded before and after TPE. Overall survival and transplant-free survival (based on King's College Hospital Criteria [KCHC]) were analyzed. RESULTS: Forty-three patients underwent TPE for ALF due to YPP. Most of them were young males. Overall survival was 34 (79.06%). In our study population, 20 patients fulfilled KCHC (Group A) and 23 did not fulfill KCHC (Group B). Both the groups showed significant improvement in alanine aminotransferase, aspartate aminotransferase, and international normalized ratio (INR) after TPE (p < 0.05). In Group B, there was significant improvement in ammonia after TPE (p < 0.05) and all 23 patients (100%) survived after TPE. In Group A, 4 underwent liver transplantation (LT), 7 survived without LT, and the remaining 9 died without LT. Mean survival after completing TPE was 41.2 ± 44.5 days in Group A and 90 days in Group B. This difference was statistically significant (p = 0.001). There was statistically significant difference in post-TPE values of INR (p = 0.012) and ammonia (p = 0.011) between non-survivors and survivors. Adverse events such as hypotension (11.62%) and minor allergic reaction (4.65%) were managed conservatively. CONCLUSION: TPE is an effective procedure in ALF due to YPP, not fulfilling KCHC for LT. In KCHC fulfilled group, though it shows LT-free survival benefit, there is requirement of prospective, large volume, multi-center study to assess its efficacy.

Membrane-based therapeutic plasma exchange in dogs: Prescription, anticoagulation, and metabolic response.

BACKGROUND: Therapeutic plasma exchange (TPE) is used increasingly in small animals to remove circulating large molecular products such as antibodies, pathogenic proteins, and protein-bound toxins. Specific, efficient, and safe protocols need to be developed. HYPOTHESIS/OBJECTIVES: To describe the technique of membrane-based TPE, the resulting physiological and metabolic changes, and to define an adequate regional citrate anticoagulation protocol. ANIMALS: Thirty-four dogs treated with TPE (2011-2017). METHODS: Retrospective review of all TPE treatments performed at the Vetsuisse Faculty, University of Bern, identified through a search of the institutional database for extracorporeal treatments. RESULTS: Sixty-four treatments were performed, resulting in 1.0 plasma volume exchange (range, 0.4-1.1). Replacement fluids included fresh frozen plasma (12%-100% volume), colloids (0%-52%), human albumin (0%-41%), and saline (0%-70%). Anticoagulation was performed with regional citrate (n = 24), systemic heparinization (n = 2), or combined (n = 38). Main relevant laboratory changes included a 24.7% decrease in total proteins (interquartile range, 16.7-31.4; P < .001), 53% in fibrinogen (-30 to 63; P = .009), 36% in bilirubin (13-43, P = .02), 9.0% in urea (0.7-15.7; P < .001), and 4.5% in creatinine (-6.6 to 10.6; P = .006). Citrate accumulation was evidenced in all dogs, more pronounced in those with renal but not with hepatic impairment. Maximal tolerable citrate rates were estimated as 5.5 and 9.0 µmol/kg/min for treatments in dogs with and without renal impairment, respectively. Complications were observed in 22 treatments (34%) and were fatal in 2 dogs. CONCLUSIONS AND CLINICAL IMPORTANCE: Therapeutic plasma exchange causes metabolic and biochemical alterations. Understanding these effects makes possible to anticipate most complications and to improve safety of the procedure.