In relation to therapeutic plasmapheresis:
a) Describe the principles involved.
b) What are the prerequisites for plasmapheresis to be effective?
c) Give six indications for its use.
d) List three types of potential complications or adverse effects associated with this
therapy, and give one example of each.
a)
Extracorporeal blood purification process to-
b)
To justify therapeutic plasmaphoresis the substances removed should
A) have a sufficiently long T1/2 such that this process results in more rapid removal than other
endogenous clearance (e.g. suppression of macromolecule production),
B) Be key ‘toxic’ factor in the pathogenesis of the disease
c)
Immunoproliferative diseases with monoclonal immunoglobulins
Hyperviscosity syndrome
Cryoglobulinaemia
Renal failure in multiple myeloma
Autoimmune diseases due to autoantibodies or immune complexes
Goodpasture’s syndrome
Myasthenia gravis
Guillain–Barre´ syndrome
Chronic inflammatory demyelinating polyneuropathy (CIDP)
Stiff-man syndrome
Systemic lupus erythematosus
Fulminant antiphospholipid syndrome
Thrombotic thrombocytopenic purpura
Haemolytic uraemic syndrome
Rapidly progressive glomerulonephritis
Coagulation inhibitors
Autoimmune haemolytic anaemia
Pemphigus
Paraneoplastic syndromes
Conditions in which replacement of plasma may be beneficial _ removal of toxins
Disseminated intravascular coagulation
Overwhelming sepsis syndromes (e.g. meningococcaemia)
Conditions in which the mechanisms are unknown
Reye’s syndrome
Removal of protein-bound or large molecular weight toxins
Paraquat poisoning
?Envenomation
d)
a. Complications related to vascular access
i. Catheter-related sepsis
b. Complications related to extracorporeal circuits
i. Hypotension/loss of blood/thrombocytopenia
c. Complications related to exchange fluid
i. More common with FFP (vs Albumin)
ii. Transfusion reactions
iii. Allergic reactions
d. Complications related to anticoagulation
i. Citrate (hypocalcaemia)
ii. Heparin (bleeding, thrombocytopenia)
Though worded slightly differently, this question is nearly identical to Question 14 from the second paper of 2010. That time, the college did not ask for the pre-requisites for effectiveness, just a list of potentially removable substances.
a) Principles of plasmapheresis
b) Characteristics of a disease process which make plasmapheresis an effective option:
c) Indications for urgent plasmapheresis
The full list can be seen in this guidelines statement: Zbigniew et al, 2010
Urgent plasma exchange:
Less urgent plasma exchange:
One should note that in their list of indications, the college noted some Grade II, III and IV recommendations, such as:
d) Complications of plasmapheresis
McLeod, Bruce C. "Therapeutic apheresis: use of human serum albumin, fresh frozen plasma and cryosupernatant plasma in therapeutic plasma exchange."Best Practice & Research Clinical Haematology 19.1 (2006): 157-167.
Reimann, P. M., and P. D. Mason. "Plasmapheresis: technique and complications." Intensive care medicine 16.1 (1990): 3-10.
Winters, Jeffrey L. "Plasma exchange: concepts, mechanisms, and an overview of the American Society for Apheresis guidelines." ASH Education Program Book 2012.1 (2012): 7-12.
Oh's Manual: Chapter 97 (pp. 993) Therapeutic plasma exchange and intravenous immunoglobulin therapy by Ian Kerridge, David Collins and James P Isbister.
Szczepiorkowski, Zbigniew M., et al. "Guidelines on the use of therapeutic apheresis in clinical practice—Evidence‐based approach from the apheresis applications committee of the American Society for Apheresis." Journal of clinical apheresis 25.3 (2010): 83-177.
Russi, Gianpaolo, and Piero Marson. "Urgent plasma exchange: how, where and when." Blood Transfusion 9.4 (2011): 356.
Weinstein, Robert. "Basic principles of therapeutic blood exchange." Apheresis: principles and practice (2003): 295-320.