Coagulation Abnormalities following Intensive Plasma Exchange on the Cell Separator

Abstract

The effects of intensive plasma exchange on the circulating levels of coagulation factors I, 11, V, VII, VIII, IX, X and antithrombin 111 were determined.During courses of daily exchange marked cumulative reductions of coagulation factors may occur, particularly in the case of factors I, I1 and X, although usually remaining above the levels considered adequate for haemostasis. The extent of cumulative reduction and subsequent recovery differed for patients with different diseases. While antithrombin 111 levels were reduced during plasma exchange the results suggest that this may be partly due to consumption as well as physical removal.The very low incidence of haemorrhagic sequelae and absence of thrombotic events following plasma exchange at this Centre is explained by the maintenance of adequate levels of coagulation factors and of antithrombin 111 even during courses of daily plasma exchange.The effects of intensive plasma exchange with coagulation factor-free replacement fluids on the coagulation profile of patients have been described previously (Keller et al, 1979). Despite the frequent occurrence of grossly abnormal values for coagulation screening tests, fibrinogen and platelet count in such patients, a remarkably low incidence of haemorrhage was observed (2.2% of 179 exchanges). Previous workers have also documented the effects ofsingle plasma exchanges on the level of individual coagulation factors (Bayer et Flaum et at, 1979).In this study the effects of intensive plasma exchange on coagulation factors I (fibrinogen), 11, V, VII, VIII, IX, X and antithrombin 111 have been followed in a heterogenous group of patients. The cumulative effects of exchange every day or every other day on the level of coagulation factors after exchange were determined. In addition coagulator factor levels were determined serially up to 24 h after selected exchanges in all patients. By delineating the kinetics of removal and reappearance of coagulation factors during plasma exchange it was hoped to clarify how normal haemostasis is maintained in patients who, after plasma exchange, exhibit very abnormal coagulation profiles.

Fibrinogen Reduction and Bleeding Complications in Plasma Exchange, Immunoadsorption and a Combination of the Two

“…When exchanging against human albumin, TPE removes proteins from the plasma by the exchange itself and microthrombosis. Proteins and other plasma constituents return to pre-treatment levels at different rates: fibrinogen is reduced the most and recovers the least of all coagulation factors, requiring 48 h to resynthesize half of the pre-treatment level [4,5]. Although a reduction of coagulation parameters does not necessarily increase the risk of bleeding [6,7], hypofibrinogenemia has been reported as a risk factor in pregnancy and surgery [8].…”

The Evidence-Based Use of FFP and Cryoprecipitate for Abnormalities of Coagulation Tests and Clinical Coagulopathy

“…Of interest, early studies investigating plasma exchange for conditions other than TTP have reported that despite repeated procedures with coagulation factor-free replacement fluids, no bleeding complications occurred, even though marked reductions of coagulation factor levels were seen. 36 Massive transfusion and DIC Very few trials have evaluated the effects of therapeutic FP in patients with bleeding who have multiple or global deficiencies of coagulation factors, e.g., DIC or massive transfusion, presumably in part reflecting the difficulties of trial design in this setting. From a pathophysiologic perspective, use of FP in this setting seems clinically appropriate.…”

Selective Fibrinogen Apheresis for Improvement in Microvascular Hemodynamics

“…Twenty-four hours after treatment, fibrinogen levels are 50% of initial levels, while it may require 72 h or more to attain levels which are 75% of pretreatment values [5] . When multiple treatments are performed over a short period (i.e.…”

“…When multiple treatments are performed over a short period (i.e. three or more treatments per week), the depletion is more pronounced and may require several days for spontaneous recovery [2][3][4][5] . Thus, given the relatively short half-life of fibrinogen (approximately 4 days), it would appear that maintaining a time-averaged reduction in the plasma fibrinogen level, and, in so doing, maintaining the beneficial effects on the microvascular circulation, one would have to perform repetitive treatments over a prolonged period of time.…”

“…The data presented in this paper do not answer that question, but several previously reported data would allow one to make a reasonable prediction. When albumin is used as the replacement fluid during standard, nonselective plasma exchange there is a depletion of fibrinogen [2][3][4][5] . Immediately after a single plasma exchange, fibrinogen will be decreased by approximately 60%.…”