Effect of therapeutic plasma exchange on coagulation parameters in patients on warfarin

Abstract

Therapeutic plasma exchange (TPE) without plasma replacement results in coagulation factor removal. Warfarin decreases the activity of vitamin K dependent coagulation factors. The combined effect of TPE and warfarin on the coagulation system has not been studied. A prospective, observational study was conducted in patients undergoing TPE while on warfarin. One plasma volume TPEs were performed on the COBE Spectra Apheresis System (Terumo BCT, Lakewood, CO) with 5% albumin. International normalized ratio (INR), fibrinogen, and factor II activity were obtained pre and post procedure. Eight patients underwent 121 TPEs that met study criteria with pre and post data. The average pre values were INR 2.09 ± 0.58, fibrinogen 263 ± 76 mg/dl, and factor II 29 ± 16% and the average post values were INR 4.12 ± 1.44, fibrinogen 105 ± 31 mg/dl, and factor II 13 ± 7%. The pre-INR was ≥2.00 for 55% of TPEs. The pre value (Y0 ) predicts the post value (Y) by the following equations Y = -0.54 + 2.21Y0 , Y =12.10 + 0.35Y0, and Y =1.83 + 0.39Y0 for INR, fibrinogen, and factor II respectively. In conclusion, pre procedure laboratory values can predict the post laboratory values for patients on warfarin receiving single plasma volume TPE with albumin replacement. The post-INR is approximately twice the pre-INR. At normal and mildly elevated pre-INR, the effect of TPE on the INR is less marked. A single plasma volume TPE decreases the plasma level by ∼65% for fibrinogen and 60% for factor II.

Effects of therapeutic plasma exchange on anticoagulants in patients receiving therapeutic anticoagulation: a systematic review

“…We identified one study evaluating the effects of TPE on the vitamin K antagonist warfarin. Zantek et al published a prospective case series of eight patients who underwent 123 TPE sessions with 5% albumin replacement while on therapeutic warfarin. Following TPE, INR measures increased approximately twofold from an average preprocedure INR of 2.09 ± 0.58 (range, 0.99–3.65) to a postprocedure INR of 4.12 ± 1.44 (range, 1.73–8.05).…”

“…Due to their known effects on coagulation proteins, therapeutic anticoagulants increase bleeding risk . However, studies suggest that, depending on the pharmacokinetic profile and timing of administration relative to the TPE procedure, anticoagulants are removed by TPE . Therefore, the combined hemostatic impact of both TPE and systemic anticoagulation is unknown.…”

Choosing Wisely for apheresis

“…By comparison, daily treatments without plasma replacement may significantly reduce clotting factors. Therefore, coagulation testing may be appropriate for a patient undergoing more frequent TPE . In those cases, fibrinogen levels can be used to assess the overall depletion of coagulation factors.…”

Hemostasis management and therapeutic plasma exchange: Results of a practice survey

“…There is very limited data published on the anticoagulant management in patients undergoing TPE . As illustrated in Table , replacement fluid containing some or all plasma or cryoprecipitate would be used by 34.5%‐67.1% of respondents with the common anticoagulants unfractionated heparin, low molecular weight heparin, and warfarin.…”