Therapeutic Plasma Exchange in Patients with Neurologic Disorders: Review of 63 Cases

  • Anil Tombak
  • Mehmet Ali Uçar
  • Aydan Akdeniz
  • Arda Yilmaz
  • Hakan Kaleagası
  • Mehmet Ali Sungur
  • Eyup Naci Tiftik
Original Article

Abstract

Therapeutic plasma exchange (TPE) is a procedure that reduces circulating autoantibodies of the patients. TPE is commonly used in neurological disorders where autoimmunity plays a major role. We report our experience with regard to the indications, adverse events and outcomes of plasma exchange in neurological disorders. Sixty-three patients were included to this retrospective study. Median age was 48 years (range 1–85), there was a predominance of males. Neurological indications included Guillain-Barrè syndrome (n = 22), myasthenia gravis (n = 21), chronic inflammatory demyelinating polyneuropathy (n = 7), polymyositis (n = 3), multifocal motor neuropathy (n = 2), acute disseminated encephalomyelitis (n = 2), neuromyelitis optica (n = 2), multiple sclerosis (n = 2), limbic encephalitis (n = 1) and transverse myelitis (n = 1). TPE was frontline therapy in 57 % of the patients (n = 36). Total number of TPE sessions was 517; median number of sessions per patient was 8 (range 1–66). TPE was done through a central venous access in 97 % and through a peripheral venous access in 3 % of the patients. Human albumin was used as replacement fluid in 49 %, hydroxyethyl starch (HES) in 49 % and fresh frozen plasma in 2 % of the cases. Adverse reactions were recorded in 60 % of the patients. Total ratio of complications in 517 TPE procedures was 10.8 % and these were mild and manageable such as allergic reactions and hypotension. Overall response rate was 81 %. Interestingly, complication and response rates were similar in both HES and human albumin groups. We conclude that TPE is an effective treatment in neurologic diseases in which autoimmunity plays an important role in the pathogenesis and HES can be used instead of albumin as replacement fluid in these disorders, since it is cost-effective, has similar efficacy and complication rates.

Keywords

Therapeutic plasma exchange Guillain-Barrè syndrome Myasthenia gravis Demyelinating disease Polyneuropathy 

References

  1. 1.
    Weinstein R (2000) Therapeutic apheresis in neurological disorders. J Clin Apheresis 15:74–128CrossRefPubMedGoogle Scholar
  2. 2.
    Rock GA, Shumak KH, Buskard NA, Blanchette VS, Kelton JG, Nair RC, Spasoff RA (1991) Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic purpura. Canadian apheresis study group. N Engl J Med 325:393–397CrossRefPubMedGoogle Scholar
  3. 3.
    Szczepiorkowski ZM, Shaz BH, Bandarenko N, Winters JL (2007) The new approach to assignment of ASFA categories—introduction to the fourth special issue: clinical applications of therapeutic apheresis. J Clin Apher 22:96–105CrossRefPubMedGoogle Scholar
  4. 4.
    Pinching AJ, Peters DK, Newsom-Davis J (1976) Remission of myasthenia gravis following plasma exchange. Lancet 308:1373–1376CrossRefGoogle Scholar
  5. 5.
    Yeh J-H, Chiu H-C (1999) Plasmapheresis in myasthenia gravis. Acta Neurol Scand 99:147–151CrossRefPubMedGoogle Scholar
  6. 6.
    Kunze K, Emskötter Th (1988) The value of plasmapheresis in the treatment of acute and chronic Guillain-Barré syndrome. J Neuroimmunol 20:301–303CrossRefPubMedGoogle Scholar
  7. 7.
    McKhann GM, GriYn JW, Cornblath SA, Ouaskey SA, Mellits ED (1988) Role of therapeutic plasmapheresis in the acute Guillain-Barré syndrome. J Neuroimmunol 20:297–300CrossRefPubMedGoogle Scholar
  8. 8.
    Susuki K, Johkura K, Yuki N, Hasegawa O, Kuroiwa Y (2001) Rapid resolution of nerve conduction blocks after plasmapheresis in Guillain-Barré syndrome associated with anti-GM1b IgG antibody. J Neurol 248:148–150CrossRefPubMedGoogle Scholar
  9. 9.
    Hao W, Davis C, Hirsch IB, Eng LJ, Walsh D, Lernmark Å (1999) Plasmapheresis and immunosupression in stiV-man syndrome with type 1 diabetes: a 2-year study. J Neurol 246:731–735CrossRefPubMedGoogle Scholar
  10. 10.
    Fogan L (1996) Progressive encephalomyelitis with rigidity responsive to plasmapheresis and immunosupression. Ann Neurol 40:451–453CrossRefPubMedGoogle Scholar
  11. 11.
    Gerraty RP, McKelvie PA, Byrne E (1993) Aseptic meningoencephalitis in primary Sjögren’s syndrome. Acta Neurol Scand 88:309–311CrossRefPubMedGoogle Scholar
  12. 12.
    Villani F, SpreaWco R, Farina L, Giovagnoli AR, Bernasconi P, Granata T, Avanzini G (2000) Positive response to immunomodulatory therapy in an adult with Rasmussen’s encephalitis. Neurology 56:248–250CrossRefGoogle Scholar
  13. 13.
    Boers PM, Colebatch JG (2001) Hashimoto’s encephalopathy responding to plasmapheresis. J Neurol Neurosurg Psychiatry 70:132CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Bibl D, Lampl C, Gabriel C, Jüngling G, Brock H, Köstler G (1999) Treatment of central pontine myelinolysis with therapeutic plasmapheresis. Lancet 353:1155CrossRefPubMedGoogle Scholar
  15. 15.
    Szczepiorkowski ZM, Winters JL, Bandarenko N, Kim HC, Linenberger ML, Marques MB, Sarode R, Schwart J, Weinstein R, Shaz BH (2010) Apheresis applications committee of the American Society for Apheresis. Guidelines on the use of therapeutic apheresis in clinical practice—evidence-based approach from the apheresis applications committee of the American society for apheresis. J Clin Apher 25:83–177CrossRefPubMedGoogle Scholar
  16. 16.
    Gwathmey K, Balogun RA, Burns T (2014) Neurologic indications for therapeutic plasma exchange: 2013 Update. J Clin Apher 29:211–219CrossRefPubMedGoogle Scholar
  17. 17.
    Kaynar L, Altuntas F, Aydogdu I, Turgut B, Kocyigit I, Hacioglu SK, Ismailogullari S, Turgut N, Erkurt MA, Sari I, Oztekin M, Solmaz M, Eser B, Ersoy AO, Unal A, Cetin M (2008) Therapeutic plasma exchange in patients with neurologic diseases: retrospective multicenter study. Transfus Apher Sci 38:109–115CrossRefPubMedGoogle Scholar
  18. 18.
    Sorgun MH, Erdogan S, Bay M, Ayyildiz E, Yücemen N, Ilhan O, Yücesan C (2013) Therapeutic plasma exchange in the treatment of neuroimmunologic disorders: review of 92 cases. Transfus Apher Sci 49:174–180CrossRefPubMedGoogle Scholar
  19. 19.
    Nogales-Gaete J, Valenzuela D, Liendo F, Vidal P, Gil G, Sáez D (2004) Plasmapheresis in neurological diseases. Experience in 140 procedures in 47 patients. Rev Mèd Chil 132:295–298PubMedGoogle Scholar
  20. 20.
    Kaya E, Keklik M, Şencan M, Yilmaz M, Keskin A, Kiki I, Erkurt MA, Sivgin S, Korkmaz S, Okan V, Doğu MH, Unal A, Cetin M, Altuntas F, Ilhan O (2013) Therapeutic plasma exchange in patients with neurological diseases: multicenter retrospective analysis. Transfus Apher Sci 48:349–352CrossRefPubMedGoogle Scholar
  21. 21.
    Lehmann HC, Hartung H-P, Hetzel GR, Stüve O, Kieseier BC (2006) Plasma exchange in neuroimmunological disorders: part 1: Rationale and treatment of inflammatory central nervous system disorders. Arch Neurol 63:930–935CrossRefPubMedGoogle Scholar
  22. 22.
    Lehmann HC, Hartung H-P, Hetzel GR, Stüve O, Kieseier BC (2006) Plasma exchange in neuroimmunological disorders: part 2. Treatment of neuromuscular disorders. Arch Neurol 63:1066–1071PubMedGoogle Scholar
  23. 23.
    Linker RA, Gold R (2008) Use of intravenous immunoglobulin and plasma exchange in neurological disease. Curr Opin Neurol Luca 21:358–365CrossRefGoogle Scholar
  24. 24.
    Clifford DB, De Luca A, Simipson DM, Arendt G, Giovannoni G, Nath A (2010) Natalizumab-associated progressive multifocal leukoencephalopathy in patients with multiple sclerosis: lessons from 28 cases. Lancet Neurol 9:438–446CrossRefPubMedGoogle Scholar
  25. 25.
    Kuwabara S (2004) Guillain-Barre´ syndrome: epidemiology, pathophysiology and management. Drugs 6:597–610CrossRefGoogle Scholar
  26. 26.
    Victor M, Ropper AH (2005) Diseases of the peripheral nerves. Principles of neurology. McGraw-Hill p, New York, pp 1110–1177Google Scholar
  27. 27.
    Shahar E (2006) Current therapeutic options in severe Guillain-Barre syndrome. Clin Neuropharmacol 29:45–51CrossRefPubMedGoogle Scholar
  28. 28.
    The Guillain-Barre Syndrome Study Group (1985) Plasmapheresis and acute Guillain-Barre syndrome. Neurology 35:1096–1104CrossRefGoogle Scholar
  29. 29.
    Van der Meche FG, Schmitz PI (1992) Dutch Guillain-Barre study group. A randomized trial comparing intravenous immune globulin and plasma exchange in Guillain-Barre syndrome. N Engl J Med 326:1123–1129CrossRefPubMedGoogle Scholar
  30. 30.
    The French Cooperative Group on Plasma Exchange in Guillain-Barre Syndrome (1997) Appropriate number of plasma exchanges in Guillain-Barre syndrome. Ann Neurol 4:298–306CrossRefGoogle Scholar
  31. 31.
    Randomised Trial of Plasma Exchange, Intravenous Immunoglobulin, and Combined Treatments in Guillain-Barre´ Syndrome (1997) Plasma exchange/sandoglobulin Guillain-Barre´ syndrome trial group. Lancet 49:225–230Google Scholar
  32. 32.
    Raphael JC, Chevret S, Hughes RAC, Annane D (2002) Plasma exchange for Guillain-Barre syndrome. Cochrane Database Syst Rev 2:CD001798Google Scholar
  33. 33.
    Burns TM (2008) Guillain-Barre´ Syndrome. Semin Neurol 28:152–167CrossRefPubMedGoogle Scholar
  34. 34.
    Gajdos P, Chevret S, Toyka K (2009) Plasma exchange for myasthenia gravis and Intravenous immunoglobulin for myasthenia gravis. The Cochrane Library, No. 1, Article ID CD002277Google Scholar
  35. 35.
    Pittayanon R, Treeprasertsuk S, Phanthumchinda K (2009) Plasmapheresis or intravenous immunoglobulin for myasthenia gravis crisis in King Chulalongkorn Memorial Hospital. J Med Assoc Thai 92:478–482PubMedGoogle Scholar
  36. 36.
    Barth D, Nabavi Nouri M, Ng E, Nwe P, Bril V (2011) Comparison of IVIg and PLEX in patients with myasthenia gravis. Neurology 76:2017–2023CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Hahn AF, Bolton CF, Pillay N, Chalk C, Benstead T, Bril V, Shumak K, Vandervoort MK, Feasby TE (1996) Plasma-exchange therapy in chronic inflammatory demyelinating polyneuropathy. A double-blind, sham-controlled, cross-over study. Brain 119:1055–1066CrossRefPubMedGoogle Scholar
  38. 38.
    Dyck PJ, Daube J, O’Brien P, Pineda A, Low PA, Windebank AJ, Swanson C (1986) Plasma exchange in chronic inflammatory demyelinating polyradiculoneuropathy. N Engl J Med 314:461–465CrossRefPubMedGoogle Scholar
  39. 39.
    Dalakas MC, Hohlfeld R (2003) Polymyositis and dermatomyositis. Lancet 362:971–982CrossRefPubMedGoogle Scholar
  40. 40.
    Le Guern V, Guillevin L (2007) Therapeutic apheresis for myositises. Transfus Apheresis Sci 36:169–172CrossRefGoogle Scholar
  41. 41.
    Elovaara I, Apostolski S, van Doorn P, Gilhus NE, Hietaharju A, Honkaniemi J, van Schaik IN, Scolding N, Soelberg Sorensen P, Udd B (2008) EFNS guidelines for the use of intravenous immunoglobulin in treatment of neurological diseases: eFNS task force on the use of intravenous immunoglobulin in treatment of neurological diseases. Eur J Neurol 15:893–908CrossRefPubMedGoogle Scholar
  42. 42.
    Marie I (2011) Therapy of polymyositis and dermatomyositis. Presse Med 40:257–270CrossRefGoogle Scholar
  43. 43.
    Galassi G, Girolami F, Ariatti A, Monelli M, Sola P (2012) Fulminant multifocal motor neuropathy: a report of two cases. Int J Neurosci 122:395–400CrossRefPubMedGoogle Scholar
  44. 44.
    Chaudhry V, Corse AM, Cornblath DR, Kuncl RW, Drachman DB, Freimer ML, Miller RG, Griffin JW (1993) Multifocal motor neuropathy: response to human immune globulin. Ann Neurol 33:237–242CrossRefPubMedGoogle Scholar
  45. 45.
    Claus D, Specht S, Zieschang M (2000) Plasmapheresis in multifocal motor neuropathy: a case report. Neurol Neurosurg Psychiatry 68:533–535CrossRefGoogle Scholar
  46. 46.
    Kanter DS, Horensky D, Sperling RA, Kaplan JD, Malachowski ME, Churchill WH (1995) Plasmapheresis in fulminant acute disseminated encephalomyelitis. Neurology 45:824–827CrossRefPubMedGoogle Scholar
  47. 47.
    Shah AK, Tselis A, Mason B (2000) Acute disseminated encephalomyelitis in a pregnant woman successfully treated with plasmapheresis. J Neurol Sci 174:147–151CrossRefPubMedGoogle Scholar
  48. 48.
    Keegan M, Pineda AA, McClelland RL, Darby CH, Rodriguez M, Weinshenker BG (2002) Plasma exchange for severe attacks of CNS demyelination: predictors of response. Neurology 58:143–146CrossRefPubMedGoogle Scholar
  49. 49.
    Watanabe S, Nakashima I, Misu T, Miyazawa I, Shiga Y, Fujihara K, Itoyama Y (2007) Therapeutic efficacy of plasma exchange in NMO-IgG-positive patients with neuromyelitis optica. Mult Scler 13:128–132CrossRefPubMedGoogle Scholar
  50. 50.
    Bonnan M, Valentino R, Olindo S, Mehdaoui H, Smadja D, Cabre P (2009) Plasma exchange in severe spinal attacks associated with neuromyelitis optica spectrum disorder. Mult Scler 15:487–492CrossRefPubMedGoogle Scholar
  51. 51.
    Llufriu S, Castillo J, Blanco Y, Ramió-Torrentà L, Río J, Vallès M, Lozano M, Castella MD, Calabia J, Horga A, Graus F, Montalban X, Saiz A (2009) Plasma exchange for acute attacks of CNS demyelination: predictors of improvement at 6 months. Neurology 73:949–953CrossRefPubMedGoogle Scholar
  52. 52.
    Wang K-C, Wang S-J, Lee C-L, Chen S-Y, Tsai CP (2011) The rescue effect of plasma exchange for neuromyelitis optica. J Clin Neurosci 18:43–46CrossRefPubMedGoogle Scholar
  53. 53.
    Weinshenker BG, O’Brien PC, Petterson TM, Noseworthy JH, Lucchinetti CF, Dodick DW, Pineda AA, Stevens LN, Rodriguez M (1999) A randomized trial of plasma exchange in acute central nervous system inflammatory demyelinating disease. Ann Neurol 46:878–886CrossRefPubMedGoogle Scholar
  54. 54.
    Keegan M, König F, McClelland R, Brück W, Morales Y, Bitsch A, Panitch H, Lassmann H, Weinshenker B, Rodriguez M, Parisi J, Lucchinetti CF (2005) Relation between humoral pathological changes in multiple sclerosis and response to therapeutic plasma exchange. Lancet 366:579–582CrossRefPubMedGoogle Scholar
  55. 55.
    Mori M, Kuwabara S, Yoshiyama M, Kanesaka T, Ogata T, Hattori T (2002) Successful immune treatment for non-paraneoplastic limbic encephalitis. J Neurol Sci 201:85–88CrossRefPubMedGoogle Scholar
  56. 56.
    Wong SH, Saunders MD, Larner AJ, Das K, Hart IK (2010) An effective immunotherapy regimen for VGKC antibody-positive limbic encephalitis. J Neurol Neurosurg Psychia 81:1167–1169CrossRefGoogle Scholar
  57. 57.
    Greenberg BM, Thomas KP, Krishnan C, Kaplin AI, Calabresi PA, Kerr DA (2007) Idiopathic transverse myelitis: corticosteroids, plasma exchange, or cyclophosphamide. Neurology 68:1614–1617CrossRefPubMedGoogle Scholar
  58. 58.
    Korach JM, Guillevin L, Petitpas D, Berger P, Chillet P (2000) Apheresis registry in France: indications, techniques, and complications. French registry study group. Ther Apher 4:207–210CrossRefPubMedGoogle Scholar
  59. 59.
    Basic-Jukic N, Kes P, Glavasa-Boras S, Brunetta B, Bubic-Filipi L, Puretic Z (2005) Complications of therapeutic plasma exchange: experience with 4857 treatments. Ther Apher Dial 9:391–395CrossRefPubMedGoogle Scholar
  60. 60.
    Henze T, Prange HW, Talartschik J, Rumpf KW (1999) Complications of plasma exchange in patients with neurological diseases. Klin Wohenschr 68:1183–1188CrossRefGoogle Scholar
  61. 61.
    Rock G, Sutton DM, Freedman J, Nair RC (1997) Pentastarch instead of albumin as replacement fluid for therapeutic plasma exchange. The Canadian Apheresis Group. J Clin Apher 12:165–169CrossRefPubMedGoogle Scholar

Copyright information

© Indian Society of Haematology & Transfusion Medicine 2016

Authors and Affiliations

  1. 1.Department of HematologyMersin University Faculty of MedicineMersinTurkey
  2. 2.Department of NeurologyMersin University Faculty of MedicineMersinTurkey
  3. 3.Department of BiostatisticsDuzce UniversityDüzceTurkey

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