Tpe sms

THERAPEUTIC PLASMA
EXCHANGE: BOON FOR
NEUROLOGICAL
DISORDER
Department of Immunohaematology & Transfusion Medicine
BLOOD BANK,SMS HOSPITAL, JAIPUR

Introduction

Apheresis – Donor Or Therapeutic
3

• Therapeutic plasma exchange (TPE) is a
procedure that reduces circulating
autoantibodies in patients. TPE is commonly
done in neurological disorders where
autoimmunity plays major role.

5
Fundamental Assumption of Therapeutic
Plasma Exchange
Reduce a pathologic substance, antigen: antibody alteration; decrease in
antibody titre; clearance of immune complexes , supply an essential
substance.

Apheresis – Centrifuge (C>>>>M)
6
The Technology

ASFA categories for TPE
Category Description
I Disorders for which apheresis is accepted as first-line
therapy, either as a primary standalone treatment or in
conjunction with other modes of treatment.
II Disorders for which apheresis is accepted as second-
line therapy, either as a standalone treatment or in
conjunction with other modes of treatment.
III Optimum role of apheresis therapy is not established.
Decision making should be individualized.
IV Disorders in which published evidence demonstrates or
suggests apheresis to be ineffective or harmful. IRB
approval is desirable if apheresis treatment is undertaken
in these circumstances.

Indications
• Neurological disorders
– Acute inﬂammatory demyelinating
polyneuropathy/ Guillain–Barre
syndrome
– Myasthenia gravis
– Chronic inﬂammatory demyelinating
polyneuropathy
– Multiple sclerosis
– Neuromyelitis optica
– Acute transverse myelitis
– Acute disseminated encephalomyelitis
• Hematological disorders
– Symptomatic leukocytosis
– Symptomatic thrombocytosis
– Atypical hemolytic uremic syndrome
– Thrombotic thrombocytopenic
purpura
– AIHA
• Renal disorders
– ANCA-associated rapidly progressive
glomerulonephritis
– Good Pasture’s syndrome
– Post renal transplant rejection (AMR)
– Rapidly progressive glomerulo-
nephritis
• Rheumatic disorders
– Systemic lupus erythematosus
• Others
– Wilson’s disease
– ABO incompatible solid organ
transplants
– Graft Versus Host disease (GVHD)

Cell Separator
Continuous Vs Intermittent

Vascular Access
• -Peripheral :Anticubital vein using one or two large bore needles (16-18
gauge).
• -Central Venous Access : Catheterize the patient with 12/11.5 no. French
dialysis catheter in Internal Jugular, Subclavian, femoral vein
• 60 and 150 mL/minute

Dosage
• Estimated plasma volume(in liters)-0.07 x wt
(kg) x(1-Hct)
• 40ml/kg

Replacement Fluids
• 0.9% normal saline
• 5% Human albumin (albumin /saline 70%/30%)
• FFP (Group compatible, cross matched)
• The primary function of the replacement fluid is to maintain intravascular
volume
- Restoration of important plasma protein
- Maintenance of colloid osmotic pressure
- Maintenance of electrolyte balance

Aims

• We report our experience with regard to
indications, adverse events and outcomes of
plasma exchange in neurological disorders

Material &
Methods

• 78 procedure were done in ICU settings with
HAEMONETICS MCS+ cell separator
• This retrospective study over a period of 1
year from 1st June 2016 to 31st May 2017.
• Detailed Analysis of all the procedures was
done by Department of Immunohaematology
& Transfusion Medicine,SMS Hospital Jaipur

Results

Age Analysis
• Median age-38 years
0
5
10
15
20
25
30
35
18-27 28-37 38-47 48-57 58-67

Gender Analysis
• Male : Female
0 20 40 60
Male
Female
59
19

Neurological indications
1. Guillain-Barrè syndrome (n = 42)
2. Myasthenia gravis (n = 24)
3. Chronic inflammatory demyelinating
polyneuropathy (n = 5)
4. Neuromyelitis optica (n = 4)
5. Multifocal motor neuropathy (n = 1)
6. Multiple sclerosis (n = 1)
7. Transverse myelitis (n = 1)

Neurological Indications
0
5
10
15
20
25
30
35
40
45
GBS MG CIDP NMO MMN MS TM

Line Of access
• Central venous access-97 %
• Peripheral venous access-3 %
Central Venous
Peripheral

Replacement Fluid
• Human albumin was used as replacement
fluid in 63 %, fresh frozen plasma & normal
saline in 100% cases.
0%
20%
40%
60%
80%
100%
Normal Saline
Fresh Frozen
Plasma Human albumin
Percentage

• Adverse event were recorded in 11 % of the
procedures
Advere Event
Uneventful
Adverse event

Adverse Events
• These were mild and manageable such as
allergic reactions, hypotension and
hypocalcaemia
Hypocalcemia
Allergic reaction
Hypotension
6
2 1

Hypocalcemia
Diagnosis Sessions
GBS 3
NMO 2
NMO 1

Discussion

• The major indication for the procedure was GBS.
• In GBS, the recommended treatment options are TPE or
Intravenous immunoglobulin (IVIG) and both have been found to be
equally effective and significantly better than the conservative
treatment for recovery from the disability.[1,2,3]
• But in IVIG resistant cases TPE in GBS has shown better outcomes.
1. Hartung HP, Willison HJ, Keiseier BC. Acute immunoinflammatory neuropathy: Update on Guillain-Barre
syndrome. Curr Opin Neurol. 2002;15:571–7.
2. van der Meche FG, Schmitz PI. A randomised trial comparing intravenous immunoglobulin and plasma
exchange in Guillain-Barre Syndrome. Dutch Guillain Barre Study Group. N Engl J Med. 1992;326:1123–9
3. Randomised Trial of Plasma exchange, Intravenous Immunoglobulin and Combined treatments in
GuillainBarre Syndrome. Plasma exchange/Sandoglobulin Guillain-Barre Syndrome Trial Group. Lancet.
1997;349:225–30.

• Because of the ease of administration and less chance of
complications, IVIG is preferred by most physicians.
• According to the report of the therapeutics and technology
assessment subcommittee of the American Academy of
Neurology on plasmapheresis in 2011, it was found that
TPE is extremely safe in experienced hands.[4]
4. Cortese I, Chaudhry V, So YT, Cantor F, Cornblath DR, Rae-Grant A. Evidence-based guideline
update: Plasmapheresis in neurologic disorders: Report of the Therapeutics and Technology
Assessment Subcommittee of the American Academy of Neurology. Neurology. 2011;76:294–300.]

• Major age group 37-48 with more of male patients.
• Majority of patients were adults and middle aged persons.
• We did not employ TPE in patients in the pediatric age group. The
procedures are often performed using evidence or experience
extrapolated from adult clinical practice, which may not be
evidence based. In addition to the clinical challenges, relevant
psychological issues technical hardware are often necessary for safe
and effective treatment in children.[5]
5.Wong EC, Balogun RA. Therapeutic apheresis in pediatrics: Technique adjustments, indications and
nonindications, a plasma exchange focus. J Clin Apher. 2012;27:132–7.

• Although complication can occur, most of these are
rapidly recognized and reversed, and are rarely serious
.
• Hypotension, allergic reactions, nausea-vomiting,
paresthesia and arrhythmias are the most common
complications of TPE which may be seen in 3-20% of
the procedures. These events are usually mild and
resolves without treatment.[6]
• Because of problems related to vascular access, 4-5%
of PE may have to be terminated.[6]
6. Basic-Jukic N, Brunetta B, Kes P. Plasma exchange in elderly patients. Ther
Apher Dial. 2010;14:161–5.

• We used FFP as the replacement fluid which has been
associated with higher incidence of hypotension and other
adverse events.
• The French Cooperative Group on plasma exchange in GBS
has recommended albumin in place of FFP, as replacement
fluid,[7] but we preferred FFP over albumin owing to the
higher cost of the latter.
7. Korach JM, Berger P, Giraud C, Le Perff-Desman C, Chillet P. Role of replacement fluids in the
immediate complications of plasma exchange. French Registry Cooperative Group. Intensive Care
Med. 1998;24:452–8.

• Neurological disorders constitute the leading indication
for TPE, followed by hematological, renal and
rheumatologic disorders.
• The complication and mortality rates do not vary
significantly among different clinical indications.
• The overall mortality rate in TPE, neurological and non-
neurological indications combined together, is
estimated to be 1-3 per 10,000 procedures.[8]
8. Ward DM. Conventional apheresis therapies: A review. J Clin Apher. 2011;26:230–
8.

Conclusion

• TPE is an effective treatment in neurologic
diseases with minimum adverse reaction.
• TPE is not only a safe and effective treatment
but also cost effective alternative to IVIG, for
various immune mediated neurological
disorders

• Always should be done in ICU setting in
presence of Transfusion medicine consultant.
• Centrifuge Cell Separator should always be
preferred rather than membrane filtration as
it is superior in every aspect of quality as well
as yield.

THANK YOU

Tpe sms

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