Analysis of Protein Removal Properties During Cryofiltration Apheresis Using the Evaflux‐5A Plasma Fractionator in a Patient With Hepatitis C Virus‐Associated Cryoglobulinemic Glomerulonephritis

Abstract

Cryofiltration (CF) is a technique in which separated plasma is chilled before being subjected to a plasma fractionator (PF), leading to cryoglobulin precipitation or cryogel formation. In CF using the Evaflux-5A as the PF, there is no consensus on the necessity of albumin supplementation, and when or how often the PF column should be washed. We analyzed the sieving effects of various solutes (albumin, IgG, IgM, LDL, HCV-RNA, and cryoglobulin) depending on transmembrane pressure (TMPPF ) during CF using the Evaflux-5A in a patient with hepatitis C virus-associated cryoglobulinemic glomerulonephritis. Five CF treatments were initially performed and a sixth one later, at disease recurrence. Quantitative detection of cryoglobulin and a marked rise in TMPPF to 400 mm Hg were observed only at the first and sixth treatment, and albumin losses during these treatments were very high, at 16.8 g, and 14.6 g, respectively, while those of others (from the second to fifth) were 6.7 g, 6.4 g, 5.9 g, and 7.0 g, respectively. The sieving coefficients (SCs) of both albumin and IgG were stable (0.8-1.0) at TMPPF < 200 mm Hg, but significantly decreased at TMPPF ≥ 200 mm Hg (P < 0.01). The SC of IgM tended to decrease at TMPPF ≥ 200 mm Hg, but not significantly, while that of LDL was zero regardless of the TMPPF . Albumin loss per treatment likely depends on degree of TMPPF rise, which is mainly affected by the patient's cryoglobulinemic status. In CF using Evaflux-5A, washing the PF column to keep TMPPF < 200 mm Hg during treatment may be a recommended for selective removal and albumin salvage.

Optimum Conditions for the Efficacy and Safety of Cryofiltration Apheresis: An Analysis of Circuit Temperatures Depending on Plasma Flow Rate and Cooling Coil Lengths/Turns

“…Cryofiltration (CF) is a double‐filtration plasmapheresis (DFPP) technique in which plasma separated by a plasma separator is chilled before being subjected to a plasma fractionator (PF), leading to cryoprotein precipitation or cryogel formation. It has been widely recognized that cryoproteins including cryoglobulin/cryofibrinogen or some immune‐complexes in cryogel induce systemic vasculitis and/or vaso‐occlusion with multiple organ involvement . In clinical CF therapy, it is necessary to provide the appropriate warming of returning blood from an extracorporeal circuit as well as effective cooling of the separated plasma before its subjection to a PF.…”

Efficacy of Cryofiltration for Treatment of Mixed Cryoglobulinemia: A Report of Four Cases

“…We have successfully treated four cases suffering from severe and progressive manifestations of cryoglobulinemic vasculitis, in which cryofiltration was safe and effective in conjunction with immunosuppressive therapies and antiviral therapies. It been applied for the treatment of cryoglobulinemic vasculitis . Three of the cases had cryoglobulinemia secondary to HCV infection.…”

“…Then remaining plasma is warmed and returned to the patient. Although its efficacy has not yet been well established, it has been applied for the treatment of cryoglobulinemic vasculitis . Here we report four cases with mixed cryoglobulinemia showing severe and progressive clinical manifestations undergoing cryofiltration treatment.…”

Aphereseverfahren bei Nierenerkrankungen und Nierentransplantation – Der aktuelle Stand des Wissens

“…Für eine verlässliche Elimination der Kryoglobuline kommen derzeit einerseits der TPE und andererseits die Kryofiltration infrage. Diese gelingt beispielsweise durch Anwendung einer Doppelfiltrations-Plasmapherese (DFPP) oder unter Einsatz spezieller Filtersysteme [15,16]. Alle Verfahren führen zu einem raschen Abfall des Kryokrit, sind aber als symptomatische Therapie zu werten, da sie nicht zur Therapie der Grunderkrankung beitragen.…”

“…Hier bieten extrakorporale Verfahren eine zusätzliche Therapieoption. Während Arbeiten unter Anwendungen des therapeutischen Plasmaersatzes keine überzeugenden Ergebnisse liefern konnten [15,16], führt die IAS zu einer raschen Beseitigung von zirkulieren Immunglobulinen und Immunkomplexen beim SLE. Damit ist dies eine therapeutische Strategie zur schnellen Beseitigung von pathogenetisch wirksamen Autoantikörpern und Immunkomplexen in Situationen, in denen keine oder keine ausreichende immunsuppressive Therapie angewendet werden kann [33].…”