Pentastarch as partial replacement fluid for therapeutic plasma exchange: Effect on plasma proteins, adverse events during treatment, and serum ionized calcium

Abstract

We compared the safety, effect on plasma proteins, and contribution to hypocalcemic toxicity of 10% pentastarch vs. 5% albumin in plasma exchange. Thirty‐two neurology patients underwent 161 plasma exchange procedures. Subjects were randomized to receive either 10% pentastarch (n = 17) or 5% albumin (n = 15) as the first ½ of colloid replacement. The second ½ of colloid replacement was 5% albumin in all cases. NaCl (plus small amounts of ACD‐A) accounted for ¼ of the total return fluid. Mean total exchange volume was 3,842.6 ± 450 ml. Hemoglobin, platelet count, coagulation parameters, and plasma fibrinogen were similar between the two groups at the outset of plasma exchange and at the time of the last (4th or 5th) procedure of the series. Immunoglobulin levels were equivalent at the outset and were reduced by plasma exchange to the same extent in the two groups. Serum albumin concentration fell significantly faster in the group receiving pentastarch. On the other hand, serum calcium, corrected for the albumin concentration, fell significantly further in the control group than in the group receiving pentastarch. Mean serum ionized calcium fell ∼25 % in procedures using only albumin but only ∼16% when pentastarch was used (P < 0.0001). This was reflected in the occurrence of hypocalcemic toxicity in 33.3% of procedures performed using only albumin but in only 8.1% of those using pentastarch (P = 0.0002). Pentastarch may be suitable for partial colloid replacement in plasma exchange and would have saved our hospital $127,050 to $434,280 in 1998 if used in all procedures. J. Clin. Apheresis 14:114–121, 1999. © 1999 Wiley‐Liss, Inc.

Early hypocalcemia in severe trauma*

“…Dilutional hypocalcemia has been previously recognized as a potentially frequent mechanism only in brain-dead patients (4), although it has also been reported during cardiopulmonary bypass (22). Hypocalcemia has been widely reported during plasma exchange, but its main mechanisms have been related to citrate anticoagulant or to the high calcium avidity of some of the colloids used such as albumin (23). In trauma patients, the well-known consequences of blood transfusion on calcium concentration probably explain why the role of fluid loading could not have been easily identified before.…”

Prophylactic infusion of calcium gluconate to prevent a symptomatic fall in plasma ionized calcium during therapeutic plasma exchange: A comparison of two methods

“…The 5% fall in [Ca 2+ ] observed in method B procedures are less than would typically be expected to result in symptoms of hypocalcemic toxicity . In fact, only 2 of the 47 TPE procedures were accompanied by symptoms, both employing method B.…”

“…The rapid infusion of pharmaceutical albumin is the major factor responsible for lowering of plasma [Ca 2+ ] during TPE . The supplementation of the albumin replacement fluid with 0.5 g (1.12 mmol) of calcium gluconate per 500 mL of albumin was highly effective at maintaining a stable level of [Ca 2+ ] throughout the TPE procedures, but we cannot be certain that the same could have been achieved using less calcium gluconate.…”

“…Hypocalcemic toxicity during therapeutic plasma exchange (TPE) principally results from the infusion of pharmaceutical albumin, which avidly binds plasma ionized calcium ([Ca 2+ ]), as the colloid replacement fluid. [1][2][3][4] We and others have shown that supplementation of the albumin replacement fluid with calcium gluconate is effective in preventing this usually mild, but frequent, complication. [5][6][7] The fall in plasma [Ca 2+ ] that occurs during donor apheresis procedures, or cytapheresis procedures such as peripheral blood hematopoietic progenitor cell collection, results from the return of plasma carrying a citrate-based anticoagulant to the donor or patient.…”

Therapeutic Apheresis: Basic Principles and Practical Aspects

“…Because large amounts of plasma protein that provided colloidal osmotic pressure were being removed, it seemed reasonable to replace the removed human plasma protein with humanderived plasma protein in the form of 5% albumin (which is >96% pure albumin) or plasma protein fraction (>83% pure albumin). 45 In some cases, 25% albumin is diluted to 5% albumin for use as replacement. Subsequently, the introduction of partial saline replacement was integrated into replacement regimens.…”