THERAPEUTIC PLASMA EXCHANGE OUR EXPERIENCE AT SALEM Dr. Aswin Kumar. S II year M.D., Immunohematology & Blood Transfusion Vinayaka Mission Medical College, Salem

INTRODUCTION APHERESIS, The Greek word ‘Pheresis’ meaning “to take away,” involves the selective removal of blood constituents from donors or patients. Desired components Red blood cell Platelets Plasma Whole blood

INTRODUCTION Therapeutic plasma exchange (TPE),is an extracorporeal blood purification technique used to remove large molecular weight substance like Pathogenic autoantibodies (e.g. Myasthenia Gravis: autoantibody) Cryoglobulins or other abnormal plasma proteins (e.g. Waldenstorm's macroglobulinemia) Immune complexes (e.g. Goodpasture's syndrome)

INDICATIONS Approximately 300,000 plasma exchange procedures are performed worldwide for various indications like Neurological - GBS,MG Renal -Good pasture syndrome Hematological-TTP, Sickle cell crisis Dermatology –Pemphigus vulgaris Toxins-Amanita phalloids, OPC

OUR EXPERIENCE We started TPE in Jan 2011 till date we have done 110 procedures on 36 patients

CASE DISTRIBUTION Total no of patients : 36

Guillain barre syndrome DIAGNOSIS No of Patients Category of Indication (AABB/ASFA) Number of procedure per patient Total procedures Guillain barre syndrome 12 I 5 60 Myasthenia gravis 4 20 Motor neuron disease 1 Parainfectious demyelinating spondyloarthropathy Paraquat poisoning 18 III

AGE DISTRIBUTION

GENDER DISTRIBUTION Total patients = 36

PROCEDURE Instrumentation : Hemonitics cell separator (MCS+) Done at : ICU under the supervision of emergency physician IV access : Central venous catheter (femoral or internal jugular vein) Anticoagulant : Acid citrate dextrose (ACD) anticoagulant is used in 1:16 ratio

KEEP AN EYE ON Pulse Blood pressure Urine output Blood flow Signs of citrate toxicity

VOLUME OF PLASMA EXCHANGE Formula: The volume of plasma to be exchanged is determined by patients estimated plasma volume (EPV) and hematocrit (hct) EPV = 0.07 x weight(kg) X (1-hct) in liters

PLASMA VOLUME EXCHANGE Percent Removed 0% 0.5 39.3% 1.0 63.2% 1.5 77.7% 2.0 86.5% 2.5 91.8% 3.0 95.0%

Efficiency of removal is greatest early in the procedure and diminishes progressively during the exchange.

NUMBER OF PROCEDURES Neuro-immunological cases Approximately 5 procedures were done on alternate days Paraquat poisoning Single large volume exchange (1-1.5 plasma volume exchange) 1 2 3 4 5

REPLACEMENT FLUIDS These r the various replacement fluids available, each one has its own advantages n disadvantages.

REPLACEMENT FLUIDS Fresh frozen plasma (30 – 40%) Colloids(6% hydroxyethyl starch) (30%) Crystalloids (30%) In our center we generally replace with normal saline,6 %HES n FFP in the ratio 1;1;3. That is one point of ns ,one point of 6% HES n 3 units of FFP each containing approx 200 ml

ADVERSE REACTIONS 27 Out of 36 patients 9 patient had a manageable adverse reaction 9

ADVERSE REACTIONS 1 patient 2 patients Hypotension was most commonly observed reaction Out of our 36 patients 3 patients became hypotension 2 pt. had fever n chills, catheter plugging was noticed in 2 pt n jst one pt showed the signs of citrate toxicity 2 patients

SIGNS OF RECOVERY In Neuro-immnological cases recovery is assessed by Recovery from assisted ventilator support Improvement in muscle power and early mobilization The outcome of neuroimmunological cases were assessed on the basis of Recovery from assisted ventilatory support Improvement in muscle power and early mobilization

CLINICAL DATA Most of the patients undergoing this procedure were under mechanical ventilation

NEURO-IMMUNOLOGICAL MORTALITY Unfortunately one of our patients could not been extubated n he expired due to respiratory failure

MORTALITY IN PARAQUAT POISONING 8 patients Out 18 pt procedure was successful on 10 patients and wasn’t on 8 patients. To mention paraquat is a herbicide. It is highly toxic, fatal compound with no specific antidote avaliable Consumption of paraquat poison for suicidal attempt increased in recent years ,consumption of 15 ml or more is considered to be a lethal dose , n main modality of treatment is charcoal hemoperfusion Wch is not avaliable in most of the centers in india. . TPE is indicated when all the treatment modalities fails.

CONCLUSION The efficacy of plasma exchange in various clinical indications are categorized as follows Category I – Standard acceptable therapy Category II – Sufficient evidence to suggest efficacy usually as adjunctive therapy Category III – inconclusive evidence of efficacy or uncertain risk/benefit ratio Category IV – Lack of efficacy in controlled trials Conclusive discussion

CATEGORY - I INDICATIONS (first line therapy ) Neurological: Guillain Barre synd Myasthenia Gravis CIDP Demyelinating polyneuropathy with IgG & IgA Hematological: TTP Sickle cell crisis ABO mismatch Marrow transplant Cryoglobinemia Others: Cutaneous T cell Lymphoma Good pasteur synd Hypercholestrolemia Phytanic acid storage disease Amanita phalloides poisoning Chronic inflammatory demyelinating polyradiculoneuropathy

CATEGORY - II INDICATIONS Renal & Others: RPGN Acute renal failure due to cast nephropathy Graves disease Digitalis toxicity Pemphigus vulgaris Bullous pemphigoid Toxic epidermonecrolysis Neurological: Lambert -Eaton synd Acute CNS inflamatory demyelinating disease Sydenham’s chorea PANDAS Refsum’s diseases Hematological: ITP Maternal-fetal Rh incompatability Coagulation factors inhibitors Pediatric autoimmune neropsychiatry disorder PANDAS Rapidly progressively glomular nephritis

CONCLUSION TPEs are successfully performed worldwide but implementation of plasma exchange in our country is still lacking The risks and complications associated with this procedure are minimal and manageable Utilization of this procedure in large scale will prove beneficiary to patients

CONCLUSION Therapeutic plasma exchange is Safe Cost effective and Efficacious when performed with expertise in appropriate indications TPE To conclude

Thank you