Is anticoagulation required in plasmapheresis? A University Hospital Experience in Bogota, Colombia

doi:10.1016/j.transci.2013.04.003

Transfusion and Apheresis Science

Volume 48, Issue 3, June 2013, Pages 301-305

https://doi.org/10.1016/j.transci.2013.04.003 Get rights and content

Abstract

Anticoagulation has been considered essential during plasmapheresis. International publications and guidelines state that anticoagulation should be administered during therapy to avoid circuit clotting and impaired effectiveness. However, anticoagulation has also been associated with bleeding, fluid and electrolyte imbalances and hematological alterations. No published studies have looked at the risk to benefit ratio of the common practice of circuit anticoagulation. We describe the experience with 367 plasmapheresis sessions, in the Hospital Universitario San Ignacio, a tertiary care center in Bogota, Colombia, where no anticoagulation is used in any case. Patient characteristics and therapy complications are described. Coagulation of circuit was never reported.

Introduction

Plasmapheresis is an extracorporeal blood purification therapy that has been frequently used in the past years. With the progress of medical knowledge and the understanding of the pathophysiology of several diseases, the role of plasmapheresis as a treatment of different clinical entities began to emerge. Today, there is clinical evidence supporting the use of this therapy in kidney, rheumatologic, hematologic, neurologic, infectious, and metabolic diseases [1], [2], [3].

Specialized equipment is required to perform proper and safe therapeutic plasma exchange. The separation of plasma and blood cells can be performed by centrifugation or by membrane filtration techniques [4], [5], [6]. Until now, anticoagulation has been considered essential during plasmapheresis regardless the technique used. Most international registries and publications about the topic describe the use of different medications and measures, like cameras or plasmafilter, to prevent circuit line clotting or obstruction [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]. Since 2008, nephrologists at the Hospital Universitario San Ignacio have performed plasmapheresis by transmembrane filtration technique without the use of anticoagulation. This is an observational study, which aims to describe the experience of the institution with this therapy. To our knowledge, this registry is the largest record published so far in Colombian population and the first one describing therapy without anticoagulation.

Section snippets

Materials and methods

This is a descriptive analysis of the plasmapheresis sessions performed at the Hospital Universitario San Ignacio between August 2008 and August 2011. The clinical and demographic characteristics of patients, techniques, indications and complications of the therapy were described based on information obtained from medical records of the institution and from the database of the nephrology service apheresis group.

The population was evaluated according to sex, age, race, type of hospital ward,

Results

Three hundred and sixty seven plasmapheresis sessions and 53 procedures were completed on 44 patients. 65.9% of the patients were women, mean age was 37% and 6.8% were black. There were 6 patients under 18 years and 3 patients over 65 years old. 53.6% of plasmapheresis sessions were performed in the Intensive Care Unit and the remainder in the general ward and outpatient clinics. The mean number of sessions per procedure was 6.9 (Table 1).

Plasmapheresis was used for 19 different diagnoses,

Discussion and conclusions

Therapeutic plasmapheresis has been used worldwide for several years. The advances in medical technology, evidence regarding its indications, and knowledge about complications and technique, have allowed a wider application of this therapy in recent years.

There are several international apheresis registries, but reports from Colombia and even from Latin America are scarce [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]. We describe 367 sessions done by membrane filtration technique.

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Therapeutic plasma exchange in rheumatic diseases: a university hospital experience
2017, Revista Brasileira de Reumatologia
Diariamente acumulam‐se evidências relacionadas com o uso da troca plasmática terapêutica (TPT) em pacientes com doenças reumáticas. O Hospital Universitário San Ignacio registrou todas as sessões de TPT feitas pelo grupo de aférese dessa instituição.
Descrever a experiência do Hospital Universitário San Ignacio na TPT em pacientes com doenças reumatológicas.
Análise observacional, retrospectiva, descritiva. Incluiu análises das sessões de TPT feitas em pacientes com doenças reumáticas de novembro de 2009 a novembro de 2013.
O grupo de aférese fez 136 sessões em 27 pacientes. A idade média foi de 43 anos (DP 18,5) e 59,3% eram do sexo feminino. Quanto ao diagnóstico, os mais frequentes foram: vasculite associada ao anticorpo anticitoplasma de neutrófilos (ANCA) seguida de lúpus eritematoso sistêmico e síndrome antifosfolipídica catastrófica. A quantidade média de sessões por paciente foi de cinco (DP 1,8) e a média de troca plasmática por paciente foi de 1,3 unidade de substituição do volume de plasma. A solução de substituição mais usada foi o plasma fresco congelado (PFC, 63,2% das sessões). De todas as sessões, 4,4% apresentaram complicações, a maioria delas relacionadas com o acesso vascular. Quinze pacientes necessitaram de terapia de substituição renal (TSR) secundária à mesma causa que levou à necessidade de TPT; três pacientes necessitaram de TSR em decorrência de outras causas além da intervenção diagnóstica de TPT e um paciente tinha sido submetido à diálise crônica.
A TPT é uma opção terapêutica necessária para o manejo de pacientes com doenças reumáticas com envolvimento renal e daqueles que são refratários ao tratamento convencional. Os resultados clínicos do presente estudo estão de acordo com o que é encontrado na literatura global.
Each day, evidence accumulates related to the use of therapeutic plasma exchange (TPE) in patients with rheumatic diseases. San Ignacio University Hospital has recorded all of the TPE sessions performed by the institution's apheresis group.
To describe the TPE experience of patients with rheumatologic diseases in a hospital setting (?).
Descriptive, observational, retrospective analysis. This study included analyses of the TPE sessions that were performed in patients with rheumatic diseases from November 2009 to November 2013.
The apheresis group performed 136 sessions in 27 patients. The mean patient age was 43 years (SD 18.5), and 59.3% of the patients were female. Regarding the diagnosis, the most frequents ones where: ANCA‐associated vasculitis followed by systemic lupus erythematosus and catastrophic antiphospholipid syndrome. The average number of sessions per patient was 5 (SD 1.8), and the average plasma exchange per patient was 1.3 plasma volume replacement units. The most used replacement solution was frozen fresh plasma (FFP; 63.2% of the sessions). Of all the sessions, 4.4% presented complications, and the majority of the complications were related to vascular access. Fifteen patients required renal replacement therapy (RRT) secondary to the same cause that created the need for TPE, 3 patients required RRT due to causes other than the TPE diagnostic intervention and 1 patient had undergone chronic dialysis.
TPE is a therapeutic alternative that is needed for the management of patients with rheumatic diseases with renal involvement and those who are refractory to conventional management. Our clinical results were in agreement with the global literature.
Plasmapheresis and other extracorporeal filtration techniques in critical patients
2017, Medicina Intensiva
Citation Excerpt :
In patients with a high risk of bleeding, the dose of anticoagulants must be considerably lower. Other authors consider that the administration of anticoagulants during plasmapheresis by membrane filtration is unnecessary.7 No published studies have looked at the risk to benefit ratio of the common practice of circuit anticoagulation, therefore further research should be conducted.
Plasmapheresis is an extracorporeal technique that eliminates macromolecules involved in pathological processes from plasma. A review is made of the technical aspects, main indications in critical care and potential complications of plasmapheresis, as well as of other extracorporeal filtration techniques such as endotoxin-removal columns and other devices designed to eliminate cytokines or modulate the inflammatory immune response in critical patients.
La plasmaféresis es una técnica extracorpórea mediante la cual se procede a la eliminación de macromoléculas del plasma que se consideran mediadores de procesos patológicos. En este artículo se revisan los aspectos técnicos, las principales indicaciones en las patologías que suelen motivar ingreso en la Unidad de Cuidados Intensivos y las potenciales complicaciones de la plasmaféresis. Así mismo, se incluye una revisión de otras técnicas de depuración extracorpórea, tales como las columnas de fijación de endotoxinas y otros procedimientos que persiguen la eliminación de citoquinas o la inmunomodulación del proceso inflamatorio en el paciente crítico.
Frequency of hemorrhagic complications in plasmapheresis without extracorporeal circuit anticoagulation, in children
2016, Transfusion and Apheresis Science
Citation Excerpt :
Likewise, it has been described that between 5.2 and 60% of patients consume coagulation factors, which recover in the 72 hours following the end of therapy, which, added to the thrombocytopenia associated with heparin, as well as that induced by plasmapheresis, makes these patients high risk for presenting hemorrhagic complications [9]. In the study carried out by Córdoba on 347 plasmapheresis sessions and 44 adult patients in whom the system was not anticoagulated, a frequency of 3.9% of hemorrhagic complications was found, similar to those found in our series of pediatric patients [10]. These are the first experiences that suggest that the treatment can be performed without anticoagulation, safely and effectively, because even now the medical literature recommends anticoagulation of the circuit with heparin or citrate, regardless of the technique being used.
The current practice of plasmapheresis at most centers employs anticoagulation of the extracorporeal circuit, which has been associated with complications. There are few studies evaluating the efficacy and safety of using plasmapheresis without any anticoagulation. We report our experience using this strategy in children (1 month to 18 years old) over a period of 5 years.
Two hundred forty-three plasmapheresis sessions without anticoagulation of the extracorporeal circuit, in 27 pediatric patients, were analyzed. Of these, 81.4% were female and the predominant age range was 12–18 years (70.3%). One hundred percent of the patients had PRISM III scale low mortality risk, and the main indication of therapy was acute rejection after renal transplantation (25.9%), followed by recurrence of focal segmental sclerosis in the transplanted kidney (17.2%). Filtration lasted more than 3 hours in 86.8% of cases, with bleeding complications in 2.9% of patients requiring early termination due to associated complications in 3.2% of cases. Other complications were paresthesias (0.41%), vomiting (5%), hypertension during (67.4%) and after therapy (64.6%), and hyperchloremia (46.5%).
In our experience, plasmapheresis without circuit anticoagulation in children is safe and effective, with a low frequency of bleeding and hydroelectrolytic complications, allowing the achievement of therapeutic goals without altering therapy duration and efficiency. Prospective studies are needed to corroborate these findings.
Double filtration plasmapheresis in the treatment of pancreatitis due to severe hypertriglyceridemia
2015, Journal of Clinical Lipidology
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In addition, anticoagulant treatment during apheresis was not used, and coagulation of circuits or impaired effectiveness along the session were not reported. Although there is lack of experience, some observational studies support this practice.15 Although further studies evaluating its clinical efficacy and the absence of negative effects are needed, plasmapheresis has proven effective in achieving significant reductions in TG levels, with a low profile of adverse effects.
Severe hypertriglyceridemia (HTG) leads to major complications such as acute pancreatitis. Lipoprotein apheresis has been proposed as a therapeutic tool for decreasing triglyceride levels, although experience is limited.
To describe our experience with double filtration plasmapheresis (DFPP) in patients with severe HTG and pancreatitis in the plasmapheresis unit of a tertiary hospital in Spain.
We recruited 4 patients with severe HTG (triglycerides [TGs] >1000 mg/dL) and acute pancreatitis. All the patients underwent DFPP as part of their treatment. Epidemiologic and laboratory data were collected before and after each plasmapheresis session.
The average TG level before plasmapheresis was 3136 mg/dL (35.44 mmol/L; range, 1306–6693 mg/dL, 14.76–75.63 mmol/L), and the average Acute Physiology And Chronic Health Evaluation (APACHE) II level before the first session was 6 (range, 3–8). All patients made a full recovery, with a significant improvement in TG levels after plasmapheresis. The mean number of sessions was 2.1 (range, 1–3), and mean TG level after plasmapheresis was 428 mg/dL (4.84 mmol/L; range, 169–515 mg/dL; 1.91–5.82 mmol/L). After the first session, the mean decrease in TG levels was 69.16% (2169 mg/dL, range, 945–5925 mg/dL; 24.51 mmol/L, range, 10.78–66.95 mmol/L), and after the last session, TG levels fell by 89.09% (2794 mg/dL, range, 945–6198 mg/dL; 31.57 mmol/L, range, 10.68–70.04 mmol/L). None of the patients developed complications related to plasmapheresis.
According to available evidence and our own experience, DFPP can be an effective and rapid treatment option in patients with severe HTG and complications. However, further research, including randomized controlled studies, is necessary.
In hospitalized patients undergoing therapeutic plasma exchange, major bleeding prevalence depends on the bleeding definition: An analysis of The Recipient Epidemiology and Donor Evaluation Study-III
2023, Journal of Clinical Apheresis
Research priorities for therapeutic plasma exchange in critically ill patients
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Is anticoagulation required in plasmapheresis? A University Hospital Experience in Bogota, Colombia

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion and conclusions

Am J Kidney Dis

Transfus Apher Sci

Transfus Apher Sci

Transfus Apher Sci

Transfus Apher Sci

Crit Care Clin

Guidelines on the use of therapeutic apheresis in clinical practice-evidence-based approach from the apheresis applications committee of the American society for apheresis

J Clin Apher

Thrombotic microangiopathies

N Engl J Med

Plasmapheresis

Comprehensive clinical nephrology

Plasmapheresis