Therapeutic plasma exchange performed in tandem with hemodialysis without supplemental calcium in the apheresis circuit

Abstract

Therapeutic plasma exchange (TPE) and hemopoietic progenitor cell (HPC) collection are apheresis procedures that can safely be performed in tandem with hemodialysis. Despite the return of citrate-anticoagulated blood to the patient during HPC collection, it is not necessary to administer supplemental calcium during these procedures because the ionized calcium concentration is restored as the returning blood passes through the dialyzer. It is not known whether this applies to TPE, in which a mixture of blood and pharmaceutical albumin, an avid binder of plasma ionized calcium, is returned to the patient through the dialyzer. We report on three dialysis-dependent patients who required TPE and underwent tandem treatments without supplemental calcium in the apheresis circuit. Overall, ionized calcium fell 4-12% (P = 0.0.024) and patients reported no symptoms of hypocalcemic toxicity. Tandem hemodialysis/TPE can be performed without supplemental calcium in the apheresis circuit. J. Clin. Apheresis 32:154-157, 2017. © 2016 Wiley Periodicals, Inc.

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

“…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.…”

“…A mean of approximately 140 mL of ACD-A was returned to our patients during the TPE procedures ( [17][18][19] The rapid infusion of pharmaceutical albumin is the major factor responsible for lowering of plasma [Ca 2+ ] during TPE. [1][2][3][4]13 The supplementation of the albumin replacement fluid with 0. A fall in plasma [Ca 2+ ] of only 5% would not be expected to be associated with symptoms.…”

“…All methods of providing prophylactic calcium supplementation may not be equally effective in cytapheresis procedures and TPE. For example, when peripheral blood hematopoietic progenitor collection is performed in tandem with hemodialysis without supplemental calcium gluconate infusion, the hemodialysis serves to maintain a stable level of [Ca 2+ ] in the patients' plasma; when plasma exchange is performed in tandem with hemodialysis under similar circumstances, plasma [Ca 2+ ] significantly decreases …”

“…For example, when peripheral blood hematopoietic progenitor collection is performed in tandem with hemodialysis without supplemental calcium gluconate infusion, the hemodialysis serves to maintain a stable level of [Ca 2+ ] in the patients' plasma 12 ; when plasma exchange is performed in tandem with hemodialysis under similar circumstances, plasma [Ca 2+ ] significantly decreases. 13 We describe herein a study that compares the efficacy of two methods of calcium gluconate prophylaxis during TPE. In particular, we have focused on plasma [Ca 2+ ] level and the occurrence of symptoms of hypocalcemic toxicity when directly adding calcium gluconate to the albumin replacement fluid vs supplemental infusion of calcium gluconate as administered during cytapheresis.…”

Optimization of infusional calcium gluconate for prevention of hypocalcemic reactions during therapeutic plasma exchange

“…[1][2][3] Unlike in donor apheresis procedures, or cytopheresis procedures such as peripheral blood hematopoietic progenitor cell collection, where the fall in plasma ionized calcium concentration ([Ca 2+ ]) results from the return of citrate-based anticoagulant with donor or patient plasma, 4,5 the fall in [Ca 2+ ] during TPE results from the rapid infusion of pharmaceutical albumin, which avidly binds plasma ionized calcium, as the colloid replacement fluid. [6][7][8][9][10] Our traditional means of prophylaxis against hypocalcemic reactions during TPE has been to add 1 g of 10% calcium gluconate (CaGlu) solution to each liter of 5% albumin replacement fluid. 11,12 This has been effective in maintaining the stability of plasma [Ca 2+ ] and avoiding hypocalcemic reactions during TPE.…”