Plasmapheresis With (and Without) CRRT

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Presentation transcript:

Plasmapheresis With (and Without) CRRT 9th International pCRRT Conference on Pediatric Continuous Renal Replacement Therapy August 31-September 2, 2017 Plasmapheresis With (and Without) CRRT Jordan M. Symons, MD University of Washington School of Medicine Seattle Children’s Hospital

Apheresis “Apheresis”: Greek, “To take away or separate” Blood perfuses extracorporeal circuit Blood components separated; selected component removed If large volume removed replacement is required Uses include therapeutic indications or for blood component harvest Hey!Pheresis®

American Society for Apheresis (AFSA) List of indications with Fact Sheets 87 diseases/medical conditions; 179 indications Rigorous review Strength of recommendation; ratings of evidence Many modalities along with TPE evaluated Cytaphersis, extracorporeal photopheresis, immunoadsorption, rheopheresis, etc.

ASFA Fact Sheet Format Schwartz et al. Journal of Clinical Apheresis 31:149–338 (2016)

Schwartz et al. Journal of Clinical Apheresis 31:149–338 (2016)

Therapeutic Apheresis in Critically Ill Patients Added challenges to TPE in ICU Critically ill patient – less stable Already limited vascular access More prone to complications HypoCa, low BP, blood product reactions (TRALI) Uncertainty of TPE effects in critically ill Theory: non-specific immunomodulation Practice: case-reports and small studies suggest improvement; RCTs do not support

Can TPE Help our Patients who have Sepsis with Multi-Organ Failure? Why TPE might work Remove inflammatory and antifibrinolytic mediators Replenish anticoagulant proteins (FFP replacement) Reverse derangement, restore hemostasis Category III indication (ASFA Guidelines 2016) “Optimum role of apheresis therapy is not established” “Decision making should be individualized” Grade 2B evidence Selective endotoxin binding columns? Some suggestion of improvement In Europe and Asia; not in United States

Plasma Exchange: Technique

Components of Whole Blood Separation and removal of individual components may be required for therapeutic need

Membrane Apheresis: Separates Components by Size PheresisPhiltrePLUS Plasmafilter: Similar to CRRT hemofilter but with larger pores

Membrane Apheresis: Separates Components by Size Larger pores will allow proteins to pass through Blood cells are restricted Membrane system can be used for plasmapheresis, not cytapheresis Creatinine 113 D Urea 60 D Glucose 180 D Vancomycin ~1,500 D Albumin ~66,000 D IgG ~150,000 D

Apheresis by Centrifugation: Separates Components by Density Hey!Pheresis® Spinning centrifuge separates blood components by density Specific component may be selected for removal by choosing appropriate layer Permits plasmapheresis and cytapheresis

Apheresis by Centrifugation: Separates Components by Density Hey!Pheresis® Blood in from patient RBCs Blood return Plasma WBCs, Plts

Fraction Removed from Plasma by Plasma Volume Replaced y=e-x Plasma volumes Remaining fraction IgG: only 45% intravascular 1.5 vol removes ~35% of total body IgG Re-equilibration within ~2 days Repeated session QOD often needed 0.223 (77.7% removed)

Plasma IgG Levels Before and After Apheresis

Pediatric Considerations Used less often in children than adults Diseases less common Physicians less familiar Technically more challenging No pediatric devices Circuit volume (blood prime?) Vascular access Complications more frequent than adults

Tandem Apheresis and CRRT Apheresis and CRRT simultaneously (same access) Avoid interruption of CRRT Avoid risks/challenges associated with CRRT restart Need appropriate preparation, procedures, systems in place to assure safety/efficiency

Apheresis in Parallel with CRRT Return to Patient NOTE: Reduce CRRT Qb by rate of apheresis Qb From Patient

Apheresis in Parallel with CRRT Return to Patient NOTE: Likely need higher Qb for membrane From Patient

Apheresis in Series with CRRT Return to Patient NOTE: Qb is the SAME From Patient

Apheresis in Series with CRRT Return to Patient From Patient

Secondary Plasma Processing Return to Patient Plasma regeneration Adsorptive columns Selective filters From Patient

Summary Therapeutic plasmapheresis may be necessary in critically ill patients, some of whom may also require CRRT Utility in MODS/sepsis remains unclear Apheresis can be combined with CRRT Newer techniques may permit plasma regeneration of more selective apheresis

Thanks for your attention!