Therapeutic plasma exchange in recurrent focal segmental glomerulosclerosis following transplantation.

Focal segmental glomerulosclerosis (FSGS) recurs in 30% of renal allograft transplants with graft loss in half of the cases. A humoral factor may be implicated. We report on the use of therapeutic plasma exchange (TPE) in 11 patients with recurrent FSGS post transplantation. Medical records from 1989-2000 were reviewed for 11 adults transplanted for biopsy proven FSGS. Ten patients developed proteinuria (x: 6.1 g; range: 3-40 g/24 h) within 2 months of transplantation. In 1 patient, proteinuria (4 g) occurred 2 years post transplantation. Biopsy in six patients revealed early recurrent FSGS, while in five, suspected recurrence was based on clinical findings. Each patient received 5-11 TPEs (x: 6) with the COBE Spectra, daily or on alternate days with 2.5-3.5 L 5% albumin as the replacement fluid. In four, FFP was included because of coagulopathy. All received immunosuppression (IS) during and after TPE. A persistent drop in 24 h urine protein (U.P.) was observed in 10/11 patients. Seven had >70% drop in 24 h U.P. following the course of TPE, while three had a reduction of 45-50%. No change occurred in 1 patient. Follow-up (9 months-5 years) of seven patients has shown a persistent U.P. of <1 g with successful allograft survival. In these patients, TPE appeared effective in early recurrent FSGS. The decrease in U.P. may result from combined TPE and IS. Although the disease is designated in category III by the ASFA, TPE should be considered early when FSGS recurrence is established.

Plasma exchange in stiff-man syndrome.

Stiff-man syndrome (STS) is a rare neurological disorder characterized by involuntary axial and proximal limb rigidity and continuous motor unit activity on electromyography (EMG). Autoantibodies to glutamic acid decarboxylase (GAD) present in 60% of the patients are implicated. We report on the use of plasma exchange (PE) in 2 patients with STS whose serum and cerebrospinal fluid were negative for GAD autoantibodies. One patient showed minimal clinical improvement following PE while the second reported subjective improvement, but not any different from that with medications. Based on the results of PE in our patients, it seems that those who are autoantibody negative are less likely to respond. Whether a more aggressive approach to PE will be beneficial remains speculative.

Femoral vascular access for large-volume collection of peripheral blood progenitor cells.

Central venous catheters are used frequently in large-volume leukapheresis to provide high flow rates for peripheral blood progenitor cell (PBPC) collection. In a retrospective study, we evaluated the safety and efficacy of short-term use of large-bore femoral venous catheters for the collection of PBPCs in 63 patients with hematologic and solid organ malignancies. All catheters were placed in an outpatient setting on the day of apheresis and remained in site if subsequent collections became necessary. A total of 101 procedures were performed. Thirty-five patients (56%) reached target levels after 1 collection. Twenty-four patients (38%) had 2 consecutive day collections while 4 patients (6%) required more than 2 collections. In this latter group, 2 patients did not have consecutive day collections. One had 2 consecutive day collections followed by a third collection 48 hours later. In the other, leukapheresis was performed for 2 consecutive days and then resumed 3 days later with 2 subsequent collections. The longest duration the catheter remained in site was 6 days. Catheter care was provided by the apheresis staff. All patients who had more than 1 collection were given instructions on how to care for their catheters at home. Only 1 patient had oozing at the catheter site during the collection. Thrombosis, mechanical, and infectious complications were not encountered. The short-term use of femoral venous catheters appears safe and effective for the collection of PBPCs.

Donor peripheral blood stem cell infusions in recipients of living-related liver allografts.

BACKGROUND: In this pilot study, donor peripheral blood stem cell (DPBSC) infusions were performed in three recipients of living-related liver transplants (LRLT). METHODS: DPBSCs were obtained by leukapheresis after mobilization with granulocyte-colony-stimulating factor (Filgrastim). Donor leukapheresis was performed on the 5th postoperative day, and half of the DPBSCs were infused into the recipient on the day of collection. The second half of the pheresed product was cryopreserved for delayed administration. RESULTS: Results from preliminary studies of chimerism in LRLT recipients, at 20 weeks posttransplant, suggested that the levels of donor cells detected in LRLT recipients treated with DPBSC infusions may be higher than those observed for recipients of cadaver donor liver allografts and vertebral body marrow infusions. CONCLUSIONS: The results of this pilot study indicate that administration of mobilized DPBSC to recipients of LRLT is a feasible procedure for both donor and recipient.

Safety of large-volume leukapheresis for collection of peripheral blood progenitor cells.

Large volume leukapheresis (LVL) reduces the number of procedures required to obtain adequate peripheral blood progenitor cells (PBPCs) for autologous hematopoietic reconstitution. LVL involves the processing of > 15 L or 5 patient blood volumes using high flow rates. We report our experience with LVL evaluating its efficiency and adverse effects in 71 adult patients with hematologic or solid organ malignancies. All were mobilized with chemotherapy and granulocyte colony-stimulating factor (G-CSF). All collections used a double lumen apheresis catheter. Mean values per LVL were as follows: blood processed, 24.6 L; patient blood volumes processed, 5.9; ACD-A used, 1,048 ml; heparin used, 6,148 units; collect time, 290 min; blood flow rate, 89 ml/min. Eighty percent of the collections were completed in one or two procedures to obtain > or = 6.0 x 10(8) MNCs/kg body weight. The most frequent side effect (39%) was parasthesia due to citrate-related hypocalcemia. This was managed with oral calcium supplements and/or slower flow rates. Post-LVL electrolyte changes were generally asymptomatic. Prophylactic oral potassium supplements were administered in 57% of cases. Other reactions included hypotension (4%), prolonged parasthesia (1.4%), and headache (1.4%). Catheter problems in 9 (13%) of the procedures were attributed to clot formation (37%) or positional effects (63%). No bleeding occurred. Post-LVL decreases in hematocrit and platelet count averaged 3.5% and 46%, respectively. Six (4%) of the procedures required red blood cell transfusions. Platelet transfusions were given in 19 (13%) of the procedures. We conclude that adverse reactions with LVL are similar to those reported for conventional PBPC collections, making it safe and efficacious as an outpatient procedure.

Automatic special case consultations in transfusion medicine.

In the past, consultations in immunohematology were usually delivered only when there was a blood or component shortage, or when the time required for compatibility testing was prolonged due to the presence of a difficult recipient antibody problem. More recently, transfusion medicine physicians have increased their role as clinical consultants concerned about the appropriate indications for blood transfusion. This communication presents a way to begin a sound program of clinical transfusion medicine consultation. The program can fit with community-wide teaching efforts, community or hospital transfusion audits, and specific physician education programs. Automatic or unsolicited consultations appear to have been both accepted well and beneficial in large hospitals and in communities where they have been provided for more than 7 years.

Positive direct antiglobulin tests with antilymphocyte globulin.

Patients receiving antilymphocyte globulin (ALG) of equine origin, for prophylactic immunosuppression following renal transplantation or for rejection episodes, develop a positive direct antiglobulin test (DAT), mainly of the IgG type. This finding may be observed as early as the first day following the administration of ALG. The cause for the positive DAT is due to the presence of antihorse globulin in the reagent antiglobulin serum reacting with ALG antigenic material coating the patients' red blood cells. The serum of some of these patients also may result in incompatible cross-matches. These serums and all of the eluates react with donor and reagent red blood cells demonstrating no particular blood group specificity.