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2nd Congress of the European Group – International Society for Apheresis

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03/23/2018 - Kleine Reitschule | 3:45pm - 5:30pm 
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Miscellaneous 3

Chairs: G. Leitner (Vienna, Austria), V. Witt (Vienna, Austria)

3:45pm
L-12
Double Filtration Plasmapheresis (DFPP) - a viable alternative to Therapeutic Plasma Exchange (TPE) in neuroimmune disorders. The Experience of the Clinical Emergency County Hospital Sibiu, Romania.
*Mihai Sava1, Alina Simona Bereanu1, Iulian Vasile Ilie2, Corina Roman-Filip3
1 University ”Lucian Blaga” Sibiu, Anaesthesia and Intensive Care, Sibiu, Romania
2 University for Veterinary Medicine, , Cluj-Napoca, Romania
3 University ”Lucian Blaga” Sibiu, Neurology, Sibiu, Romania
Abstract text :

Double filtration plasmapheresis (DFPP) is a cascade filtration with two steps. Firstly, plasma is extracted from the blood and then circulated through a second filter named plasma fractionator which retains the larger substances that are to be found in the plasma such as IgG, IgM, LDL-cholesterol, Lp(a), triglycerides, fibrinogen or viruses. The rest of the plasma is returned to the patient. The advantage of this method is that there is no need to give human albumin or FFP as a substitution fluid, and, even if it is necessary to do so, the amount is very small. The indications of this method are, in theory, the same as for the conventional therapeutic total plasma exchange (TPE). The 2016 American Society for Apheresis (ASFA) indications for DFPP are: age related macular degeneration (dry), familial hypercholesterolemia- LDL apheresis, lipoprotein (A) hyperlipoproteinemia - LDL apheresis. ASFA also considers DFPP to be an appropriate alternative to TPE for: myasthenia gravis, neuromyelitis optica spectrum disorders (NMOSD), renal transplantation ABO incompatible, Goodpasture"s syndrome, cryoglobulinemia, hyperviscosity in monoclonal gammopathies, phytanic acid storage disease (Refsum"s disease). There are several studies in literature about the use of DPPP for other diseases, like: Guillain-Barre syndrome, thrombotic thrombocytopenic purpura, several renal autoimmune diseases, acute antibody mediated renal rejection, rheumatoid arthritis, chronic hepatitis C, after coronary stenting, type 1 diabetes with insulin antibodies and so on. In the Intensive Care Unit of the Clinical Emergency County Hospital Sibiu we perform TPE and DFPP since 2013, mostly for neuroimmune disorders. We had the greatest experience in the last 2 years. In 2016-2017 we performed TPE on 21 patients (a total of 78 sessions) and DFPP on 10 patients (23 sessions). Out of these pacients, 17 treated with TPE and 9 with DFPP had neuroimmune disorders. 12 patients of those with TPE (70%) and 5 of those with DFPP (55%) showed prominent neurological improvement. There were five hypotensive episodes out of the 23 DFPP sessions (21%) that responded promptly to gelatin solution infusion. There was no bleeding reported associated with the procedure and no infection at the catheter insertion site. Three sessions were prematurely stopped due to high transmembranary pressure in the plasmaseparator. There were no deaths associated to the DFFP procedures.    



4:00pm
L-13
Cytokine modulation in abdominal septic shock following acute care surgery
*Takuya Ueno1,2, Toshiaki Ikeda3, Takayoshi Yokoyama1, Yu Kihara1, Osamu Konno1, Yuki Nakamura1, Hitoshi Iwamoto1, Shigeyuki Kawachi4, Anil Chandraker2
1 Tokyo Medical University Hachioji Medical Center, Department of Kidney Transplantation Surgery, Tokyo, Japan
2 Brigham and Women's Hospital, Harvard Medical School, Transplantation Research Center, Renal Division, Boston, United States
3 Tokyo Medical University Hachioji Medical Center, Division of Critical Care and Emergency Medicine, Tokyo, Japan
4 Tokyo Medical University Hachioji Medical Center, Department of Digestive and Transplantation Surgery, Tokyo, Japan
Abstract text :

Background: Early recovery from shock improves prognosis in septic shock patients. Our first systematic review of hemoperfusion using an immobilized polymyxin B fiber column for endotoxin removal (PMX-Direct Hemoperfusion; PMX-DHP, Toray Industries Inc., Tokyo, Japan) showed that PMX-DHP lowers mortality from sepsis (Crit Care, 2007). We also reported levels of inflammatory mediators such as endotoxin, TNFα, IL-1b, and IL-6 are decreased after PMX-DHP in those patients. However, no data are yet available on the importance of Continuous Renal Replacement Therapy (CRRT) in regulating hemodynamics through cytokine modulation in septic shock patients following acute care surgery.


In the current study, we determined whether cytokine modulation by Continuous Renal Replacement Therapy (CRRT) following acute care surgery resulted in stable hemodynamics in them.


Methods: 66 septic shock patients requiring 2 hours direct hemoperfusion therapy with PMX-DHP were included. 36 patients of them also received continuous hemodiafiltration (CHDF; Toray Industries Inc.) after performing PMX-DHP. Circulatory dynamics and levels of inflammatory mediators, namely IL-6, IL-1ra, and PAI-1 were assessed before, immediately after, and 24 hours initiation of PMX-DHP.


Results: Mean Arterial Pressure (MAP) rose intentionally by PMX-DHP just after enforcement 24 h later (p<0.01). Levels of IL-6, IL-1ra, and PAI-1 significantly decreased after PMX-DHP (p<0.05) and this trend was observed up to 24 h post initiation of PMX-DHP (p<0.05) (Fig. 1). IL-6 modulation by PMX-DHP was enhanced with using CHDF and there was a significant correlation between IL-6 and MAP (p<0.0001) (Fig. 2).


Conclusions: Our data showed employing CRRT as cytokine modulators could be an additional therapeutic strategy to improve septic shock outcomes.



4:15pm
L-14
Effect of lipoprotein apheresis (LA) on an antibodies associated neuromuscular disease. A case report
*Sergey Tselmin1, Ulrich Julius1, Bernd Hohenstein1
1 University Hospital and Faculty of Medicine Carl Gustav Carus, Lipidology, Department of Internal Medicine III, Dresden, Germany
Abstract text :

Introduction


The pleiotropic effects of LA including the decrease of immunoglobulins at the double filtration plasmapheresis (DFPP) are well known. However this "side effect" can be positive in patients with co-occurring autoimmune diseases.  We report a benefit from Membrane Filtration Optimized Novel Extracorporeal Treatment (MONET) in a patient with myasthenia gravis (MG), coexisting with a severe coronary heart disease (CHD).


Material and Methods


A female patient, aged 60, has been suffering from progressive CHD associated with high elevated LDL-Cholesterol (LDL-C) since the age of 46. The MG has been existing for 18 years and is characterized by Acetylcholine Receptor (AChR) antibodies, a severe generalized form and an intolerance against immunosuppressives. Because of total statin incompatibility the dyslipidemia is treated with LA (MONET) resulting beyond the expected LDL-C reduction in easing neuromuscular symptoms.


Results


The patient reports a marked relieve of muscle weakness during three to four days after the LA session that is confirmed by a significant reduction of Besinger-Score and Pyridostigmin daily dose. The AChR antibody level is decreased after one treatment by 66.7% that is comparable with the LDL-C reduction. The intervals between administrations of immunoglobulin-medicines could be doubled.


Conclusions


MONET seems to be a very potent option for AChR antibody associated MG. The known DFPP methods for MG treatment are not suitable for elimination of atherogenic lipoproteins. The LA with DFPP methods could be recommended in patients with some coexisting autoimmune disorders.     



4:30pm
L-15
Extracorporeal Photochemotherapy: Single Day, Off Line Protocol. Analysis Of Outcomes.
*Maria Mariano1, Mirco Bevini1, Roberta Malavolti1, Angela Cuoghi2, Paola Bresciani2, Valeria Pioli2, Andrea Gilioli2, Giovanni Ceccherelli1, Mario Luppi2, Franco Narni2
1 Policlinic Hospital, Transfusion Medicine, Modena, Italy
2 University of Modena and Reggio Emilia, Oncology and Hematology Department, Modena, Italy
Abstract text :

Introduction: ECP should still be considered a work-in-progress therapy not only for its uncertain mechanism but also for the numerous and different protocols used worldwide. The original Therakos "in-line" ECP cycle was on two-consecutive-day. Likewise, many "off-line" ECP centres emulate the same schedule despite differences in a variety of factors. There are no evidences that "single and consecutive sessions" are equally effective. Indeed, the ECP paradox is its ability to produce the same result no matter what protocol is used.


We retrospectively present our data on outcomes of patients treated with off-line-ECP, in standard pathologies, on single-day session: our patients have the same outcomes reported by others.


Methods: 15 years" ECP experience, single centre, off line protocol, single day sessions.


Cell separator: Cobe Spectra and OPTIA.


Cell were collected in EVA bags –sterilely pre-assembled to separation kit-, 8-MOP was added at 1/100 ml ratio, irradiation firstly by Vilber-Lourmat, later by Macogenic device, before transfusion.


Patients: not-responders, intolerant or dependent to first line steroid therapy.


ECP schedule:



  • aGVHD: 2-3 ECP sessions/week, until maximum response, then tapered.

  • cGVHD, organ graft rejection, Sezary Syndrome and autoimmune disease: 2 ECP sessions/week, until response, then tapered.


Control quality: cell apoptosis, haematocrit and sterility.


Results:


Patients: 2,170 ECPs in 88 patients: aGVHD 39, cGVHD 29, Sezary S. 11, organ rejection 5, autoimmunity 4.


Outcomes:



  • aGVHD: 87% ORR, 75% CR (100% ORR in grade I-IV skin; 100% ORR in grade I-IV GI-Skin-liver; 61% in grade III-IV GI-Liver);

  • cGVHD: 76% ORR - 68% CR (90% CR in skin grade mild-severe; 100% ORR in scleroderma grade mild, 66% in grade moderate-severe; 66% ORR in Liver-Bronchiolitis Obliterans);

  • Sezary Syndrome: 80% PR;

  • Organ Rejection: 75% PR;

  • Autoimmune disease: 25% PR.


Steroids were tapered in 100% aGVHD pts and 86% cGVHD pts.


Conclusion:


Our data are consistent with those of in-line and off-line protocols on two consecutive days. Indeed, as many ECP experts suggest, there is no obvious rationale for the two consecutive sessions in the off-line setting as the amount of mononuclear cell collected is high and, anyway, doesn"t seem so important for good outcomes. That could be true even for in-line protocol.