A Retrospective study of complications of therapeutic plasma exchange in myasthenia

Guptill, Jeffrey T.; Oakley, Darlene; Kuchibhatla, Maragatha; Guidon, Amanda C.; Hobson‐Webb, Lisa D.; Massey, Janice M.; Sanders, Donald B.; Juel, Vern C.

doi:10.1002/mus.23508

Cited by 33 publications

(33 citation statements)

References 36 publications

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“…Nevertheless, several studies describe increased complications rates with central lines in this setting [ 41 , 42 ]. As a less invasive alternative, successful TPE with peripheral venous access was demonstrated even in neurology patients [ 42 , 43 ]. Central lines offer a continuous high blood flow rate and a straight workflow in the clinical setting.…”

Section: Discussionmentioning

confidence: 99%

Assessment of Hemostasis after Plasma Exchange Using Rotational Thrombelastometry (ROTEM)

et al. 2015

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BackgroundTherapeutic plasma exchange (TPE)-based protocols immediately before cadaveric donor kidney transplantation have been extensively used in highly sensitized recipients. Plasma is generally preferred over human albumin as replacement fluid to avoid depletion of coagulation factors and perioperative bleeding. The aim of this study was to estimate bleeding risk after TPE replaced with albumin using rotational thromboelastography (ROTEM).MethodologyTen patients without overt coagulation abnormalities underwent TPE. Standard laboratory coagulation tests (thromboplastin time, activated partial thromboplastin time (aPTT), international normalized ratio (INR), thrombin clotting time, fibrinogen levels and antithrombin activity) were compared with thrombelastometry analysis (EXTEM and INTEM tests) before and after TPE.Principal FindingsTPE significantly reduced fibrinogen levels (482 ± 182 vs. 223 ± 122 mg/dL), antithrombin activity (103 ± 11 vs. 54 ± 11 %), and prolonged aPTT (28 ± 3 vs. 45 ± 8 s), thromboplastin time (108 ± 11 vs. 68 ± 11 %), INR (0.95 ± 0.06 vs. 1.25 ± 0.16), and thrombin clotting time (18 ± 2 vs. 20 ± 3 s). INTEM and EXTEM analyses revealed significantly prolonged clot-formation time and reduced maximum clot firmness.Conclusions/SignificanceTPE replaced with albumin induces significant changes in global hemostasis parameters thus potentially increasing bleeding risk. Therefore, pretransplant TPE should be considered carefully in indicated patients before kidney transplantation. The role of the ROTEM point-of-care test to estimate the risk of bleeding in renal transplantation needs to be evaluated in further studies.

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Section: Discussionmentioning

confidence: 99%

Assessment of Hemostasis after Plasma Exchange Using Rotational Thrombelastometry (ROTEM)

et al. 2015

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“…It is more invasive, more labor-intensive and more expensive than ivIG (97). PE should be performed via peripheral venous access, where feasible, but central catheters may be necessary in some which pose additional risks of an infection source if mishandled or if left in situ for too long (98). The same dose of ivIG could be administered over a shorter period for example 2-3 days if tolerated by the patient.…”

Section: The Mg Patient In Crisismentioning

confidence: 99%

A Practical Approach to Managing Patients With Myasthenia Gravis—Opinions and a Review of the Literature

Farrugia

Goodfellow

2020

Front. Neurol.

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When the diagnosis of myasthenia gravis (MG) has been secured, the aim of management should be prompt symptom control and the induction of remission or minimal manifestations. Symptom control, with acetylcholinesterase inhibitors such as pyridostigmine, is commonly employed. This may be sufficient in mild disease. There is no single universally accepted treatment regimen. Corticosteroids are the mainstay of immunosuppressive treatment in patients with more than mild MG to induce remission. Immunosuppressive therapies, such as azathioprine are prescribed in addition to but sometimes instead of corticosteroids when background comorbidities preclude or restrict the use of steroids. Rituximab has a role in refractory MG, while plasmapheresis and immunoglobulin therapy are commonly prescribed to treat MG crisis and in some cases of refractory MG. Data from the MGTX trial showed clear evidence that thymectomy is beneficial in patients with acetylcholine receptor (AChR) antibody positive generalized MG, up to the age of 65 years. Minimally invasive thymectomy surgery including robotic-assisted thymectomy surgery has further revolutionized thymectomy and the management of MG. Ocular MG is not life-threatening but can be significantly disabling when diplopia is persistent. There is evidence to support early treatment with corticosteroids when ocular motility is abnormal and fails to respond to symptomatic treatment. Treatment needs to be individualized in the older age-group depending on specific comorbidities. In the younger age-groups, particularly in women, consideration must be given to the potential teratogenicity of certain therapies. Novel therapies are being developed and trialed, including ones that inhibit complement-induced immunological pathways or interfere with antibody-recycling pathways. Fatigue is common in MG and should be duly identified from fatigable weakness and managed with a combination of physical therapy with or without psychological support. MG patients may also develop dysfunctional breathing and the necessary respiratory physiotherapy techniques need to be implemented to alleviate the patient's symptoms of dyspnoea. In this review, we discuss various facets of myasthenia management in adults with ocular Farrugia and Goodfellow Practical Approaches to Myasthenia Management and generalized disease, including some practical approaches and our personal opinions based on our experience.

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“…Venous access for plasma exchange can be achieved by central venous catheters or peripheral veins, and the preferred method varies among providers. Very recently, one retrospective study showed that peripheral veins access can be used successfully in most myasthenic patients and reduces the risk of serious and even lethal complications of the procedure .…”

Section: Introductionmentioning

confidence: 99%

Myasthenia gravis: an update for the clinician

Sieb

2014

Clinical and Experimental Immunology

220

151

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OTHER ARTICLES PUBLISHED IN THIS SERIESParaneoplastic neurological syndromes. Clinical and Experimental Immunology 2014, 175: 336-48. Diagnosis, pathogenesis and treatment of myositis: recent advances. Clinical and Experimental Immunology 2014, 175: 349-58. Disease-modifying therapy in multiple sclerosis and chronic inflammatory demyelinating polyradiculoneuropathy: common and divergent current and future strategies. Clinical and Experimental Immunology 2014, 175: 359-72 SummaryThis paper provides a thorough overview of the current advances in diagnosis and therapy of myasthenia gravis (MG). Nowadays the term 'myasthenia gravis' includes heterogeneous autoimmune diseases, with a postsynaptic defect of neuromuscular transmission as the common feature. Myasthenia gravis should be classified according to the antibody specificity [acetylcholine, muscle-specific receptor tyrosine kinase (MuSK), low-density lipoprotein receptor-related protein 4 (LRP4), seronegative], thymus histology (thymitis, thymoma, atrophy), age at onset (in children; aged less than or more than 50 years) and type of course (ocular or generalized). With optimal treatment, the prognosis is good in terms of daily functions, quality of life and survival. Symptomatic treatment with acetylcholine esterase inhibition is usually combined with immunosuppression. Azathioprine still remains the first choice for long-term immunosuppressive therapy. Alternative immunosuppressive options to azathioprine include cyclosporin, cyclophosphamide, methotrexate, mycophenolate mofetil and tacrolimus. Rituximab is a promising new drug for severe generalized MG. Emerging therapy options include belimumab, eculizumab and the granulocyte-macrophage colonystimulating factor. One pilot study on etanercept has given disappointing results. For decades, thymectomy has been performed in younger adults to improve non-paraneoplastic MG. However, controlled prospective studies on the suspected benefit of this surgical procedure are still lacking. In acute exacerbations, including myasthenic crisis, intravenous immunoglobulin, plasmapheresis and immunoadsorption are similarly effective.

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A Retrospective study of complications of therapeutic plasma exchange in myasthenia

Abstract: PV access for TPE can be used successfully in most MG patients and may reduce morbidity of the procedure.

Cited by 33 publications

References 36 publications

Assessment of Hemostasis after Plasma Exchange Using Rotational Thrombelastometry (ROTEM)

Assessment of Hemostasis after Plasma Exchange Using Rotational Thrombelastometry (ROTEM)

A Practical Approach to Managing Patients With Myasthenia Gravis—Opinions and a Review of the Literature

Myasthenia gravis: an update for the clinician

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