Selected questions and answers given by apheresis medicine experts at TAA 2010
✍ Scribed by Rasheed A. Balogun; Emaad M. Abdel-Rahman
- Publisher
- John Wiley and Sons
- Year
- 2011
- Tongue
- English
- Weight
- 93 KB
- Volume
- 26
- Category
- Article
- ISSN
- 0733-2459
No coin nor oath required. For personal study only.
✦ Synopsis
We are seeing more 5-and 6-L plasma-volume exchanges in chronic inflammatory demyelinating polyneuropathy (CIDP) patients. What are your thoughts on that?
DR. WARD: The principles in CIDP are hard to elucidate; it may not be an IgG-based disease in all cases. If you exchange 5 or 6 L, you deplete less as you go down the curve. A lot of chronic-plasma exchange CIDP patients can be maintained on once a week or once every 2 weeks, so the temptation is to do more on the day that you see them. But I do not think that the last part of the procedure does very much, once you have exchanged more than 1.5 plasma volumes.
Q: Can you comment on the use of AV fistulas for long-term plasma exchange treatment? DR. WARD: There is definitely a place for AV fistulas. The complications of indwelling catheters apply to plasma exchange and other apheresis patients, perhaps even more than to dialysis patients. Many apheresis patients do not have very good immune systems, and furthermore, a lot of plasma exchange patients have progressive immunoglobulin depletion or are on immunosuppressive therapies as well, so the risk of indwelling catheter infection is high. In long-term patients, fistulas are appropriate.
Q: Who in your center makes the determination whether the patient would be better off having an AV fistula-the treating nephrologist or the physician who referred the patient for apheresis?
DR WARD: I think that the apheresis physician needs to make the determination.
Q: Do you have any trouble with fistulas? We cannot get our surgeons to do them.
DR WARD: AV fistulas have been used in other types of patients, including long-term brittle diabetics; several apheresis patients have not had AV fistulas clot in years. Some of them will clot, but for the patient who is having trouble with other access, it is a great kindness to put an AV fistula into them.
DR. BALOGUN/MS. KAUFMANN:
We try to avoid catheters as much as we can; most of our outpatients have fistulas.
Q:
Has there been a decline in TRALI events with the transfusion of blood products?
DR. WINTERS: Yes. The U.S. has switched to male-only plasma when possible; the types you often run short on are B and AB, and you have to supplement with female-but yes, there has been a decline. At Mayo, we are working on a multicenter clinical trial, looking at the incidence of TRALI, and those results will be published.
Q: Are there any indications for when to use twicea-day apheresis?
DR. WINTERS: Only in the context of refractory TTP patients.
DR. BALOGUN: I agree. We think it might actually decrease platelet count.
DR. WARD: Ed Taft had two patients who got thrombocytopenia super-added on their TTP because of folate deficiency due to being plasmapheresed so hard.
Q: How about cytapheresis or leukapheresis in patients with very high white-cell counts?
DR. WARD: In a leukapheresis case with a very high myeloblast count, you often want to reduce that by 90%; that would be an indication for doing leukaphersis twice or doing one long session. When you do