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Therapeutic Plasma Exchange Using Membrane Plasma Separation

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Therapeutic Plasma Exchange Using Membrane Plasma Separation CJASN ePress. Published on April 20, 2020 as doi: 10.2215/CJN.12501019 Therapeutic Plasma Exchange Using Membrane Plasma Separation Sadiq Ahmed 1 and Andre Kaplan2 Abstract Therapeutic plasma exchange is a blood purification technique designed for the removal of large molecular weight toxins such as pathogenic antibodies and lipoproteins. Plasma exchange can be performed either by membrane 1Division of separation or centrifugation. Centrifugal plasma exchange is more common in the United States while Nephrology Bone and membrane separation is more popular in Germany and Japan. The membrane separation technique is similar to Mineral Metabolism, the ultrafiltration procedures performed with a standard dialysis machine but in which the membrane’s pores University of Kentucky, Lexington, are large enough to allow removal of all circulating molecules while retaining the cellular components. The Kentucky current availability of plasma separation membranes compatible with CRRT systems has dramatically increased 2Division of the potential for almost all nephrologists to perform these treatments. This review describes the membrane Nephrology, separation techniques available in the United States, the practical aspects of ordering and operating a membrane University of Connecticut Health separation plasma exchange procedure and its possible complications. Center, Farmington, CJASN 15: ccc–ccc, 2020. doi: https://doi.org/10.2215/CJN.12501019 Connecticut Correspondence: Introduction replacement by an equal volume of appropriate fluid Dr. Sadiq Ahmed, Therapeutic plasma exchange is a procedure carried Division of purify the blood by removing the pathogenic mole- Nephrology Bone and out for various life-threatening and debilitating diseases cules responsible for certain diseases. The substances Mineral Metabolism, as a principal mode of treatment or as an adjunct with removed by plasma exchange are abnormally pro- University of other therapies. In this procedure, plasma is separated duced in the body in various diseased states. These Kentucky, 800 Rose from the cellular components of blood. The removed high molecular weight pathogenic molecules, such as Street, Room MN564, Lexington, KY 40536- plasma is discarded and replaced with a colloid, a Igs, proteins, or immune complexes (Table 1) (4,5), 0298. Email: Sadiq. combination of crystalloid and colloid (1), or fresh cannot be removed from the blood by conventional [email protected] frozen plasma. Separation of plasma from the cellular methods, such as dialysis or hemofiltration, due to components of blood can be achieved by two differ- their large size. Urgent removal of these molecules is ent techniques: either by membrane separation or by necessary to prevent ongoing organ damage because centrifugation. Plasma separation by centrifugation is these molecules have long half-lives; additionally, commonly performed by pathologists, transfusion therapies aimed at suppression of their production medicine experts, and nephrologists. Alternatively, take weeks or months to be effective. Rapid removal the concept of membrane separation of plasma using of these large molecules by plasma exchange reduces a filtration device is very similar to hemofiltration or morbidity and mortality. The commonly removed ultrafiltration using a dialysis machine and hence, molecules and their molecular weights are described mainly performed by nephrologists. Membrane fil- in Table 1 (4,5). tration plasma exchange is also referred to as mem- brane plasma separation. Although very popular in Japan and Germany (2), in the United States, the Mechanism of Plasma Separation by Membrane membrane separation technique, although gaining pop- Filtration Plasma Exchange ularity (3), is used less often compared with centrifugal Separation of plasma from the blood’s cellular com- plasma exchange. Nephrologists and dialysis nurses are ponents can be accomplished by filtration through a naturally familiar with this technique because they are highly permeable membrane. This methodology sepa- experts in using these machines. This review article will rates the blood into its cellular and noncellular compo- discuss the basic principles, mechanisms, instruments, nents by subjecting it to sieving through a membrane complications, and practical aspects of prescribing with pores that allow the plasma proteins to pass but therapeutic plasma exchange by membrane separation. retain the larger cellular elements within the blood path (Figure 1). Twenty-five years after the first centrifugal plasma exchange procedure in a patient with multiple Principles of Blood Purification by Membrane myeloma in 1952, the membrane separation technique Separation Plasma Exchange was introduced in 1978 (6,7) as an alternative to the The separation and removal of plasma from the patient existing centrifugal technique. Membrane separation by a semipermeable membrane and its simultaneous plasma exchange is very similar to the operation of a www.cjasn.org Vol 15 September, 2020 Copyright © 2020 by the American Society of Nephrology 1 2 CJASN Table 1. Size and distribution of some of the proteins removed by therapeutic plasma exchange Protein Concentration, mg/ml M.W. 3 103 D Percentage Intravascular IgG (except IgG3 subclass) 12 150 45 IgG3 0.7 150 64 IgMa 0.9 950 78 IgA 2.5 160 42 IgD 0.02 175 75 IgE 0.0001 190 45 Albumin 45 66 44 C3 1.4 240 67 C4 0.5 200 66 Fibrinogen 3–434081 Factor VIII 0.1 100–340 71 Antithrombin III 0.2 56–58 45 Lipoprotein cholesterol 1.5–2.0 1300 .90 M.W., molecular weight. Modified from refs. 4 and 5, with permission. conventional dialysis machine running in ultrafiltration contains all of the noncellular components of the patient’s mode (Figure 2) or a continuous RRT (CRRT) in venovenous plasma (Figure 1); as plasma is filtered out, it is replaced hemofiltration mode. In membrane separation plasma simultaneously with appropriate fluids (usually albumin exchange, instead of a regular filter designed for the or fresh frozen plasma [FFP]) in equal volume to the removal of small and “middle” molecules, a special filter plasma removed to prevent hemodynamic compromise. with large pores (0.3–0.5 mm) is used. Pore sizes of these The removal rate of any given plasma component de- membranes are usually 0.5 mm or less, thus easily rejecting pends on the plasma filtration rate and its sieving co- the smallest cellular component, the platelets (3 mm). Blood efficient (ratio of a given plasma protein or solute drawn from a central venous access, such as a dialysis concentration between the filtrate and the blood side of catheter, is passed through this special plasma filter before it the membrane). With the currently available modern is returned to the patient (Figure 2). Because of the large plasma filtration membranes, the sieving coefficient of pores, the ultrafiltrate or effluent produced in this manner even the largest molecules, weighing .1 million D (LDL Figure 1. | Schematic section of a hollow fiber for plasma exchange. Whole blood flows lengthwise along the interior of the fiber, whereas its plasma components, such as Igs, clotting factors, fibrinogen, and albumin, pass through the pores in the fiber wall and collect outside the fiber. The wall of the hollow fiber functions as the separating membrane with a pore size that allows penetration by plasma but not by the blood’s cellular components (red blood cells [RBCs], white blood cells [WBCs], and platelets). CJASN 15: ccc–ccc, September, 2020 Membrane Separation Plasma Exchange, Ahmed and Kaplan 3 purpose, but most are not available in the United States (2,8,9). Practitioners in the United States have only two choices of filters for membrane separation plasma exchange. They are the Prismaflex TPE-2000 plasma filter (Baxter) and the Plasmaflo OP-05W (Asahi Kasei Medical Company Ltd. Japan). The physical properties of these two filters are very similar but different from a conventional dialyzer, and they are compared in Table 2. Efficacy of Membrane Separation in Comparison with Centrifugal Plasma Exchange Membrane separation is limited to plasma exchange only and cannot separate the cellular components of blood. For this reason, it cannot be used for cellular apheresis procedures, such as red blood cell exchange, leukapheresis, platelet removal, and harvesting stem fi Figure 2. | Blood flowing through the plasma filter, plasma separa- cells. The plasma exchanging ef ciency of membrane tion and infusion of replacement solution, and return to the patient. separation is similar to the centrifugal technique due to a very high (close to 100%) sieving coefficient(ratioofthe concentrations of the molecules between the filtrate and cholesterol, etc.), is essentially “one.” Thus, the concen- the blood) of the plasma proteins and the pathogenic tration of these larger proteins in the removed plasma molecules (10). Studies from the 1980s showed that flat- (effluent) is essentially equal to that in the patient’s plate parallel membranes had similar efficacy to centrif- circulating plasma. ugal plasma exchange (4). A recent prospective study compared membrane filtration by the Plasmaflo filter with the centrifugal separation by the Spectra Optia and found that both systems are equally effective in removing Igs Membrane Separation Plasma Exchange Options (Figure 3) (11); however, the centrifugal procedure required Available in the United States less time (11,12). In a retrospective study, membrane sepa- The flat parallel plate membrane (Centry TPE; Cobe) (8) ration was also found to be effective in the pediatric was the first membrane separation plasma exchange
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