Plasmatherapies
Plasmapheresis
The term plasmapheresis encompass different techniques (filtration or adsorption on plasma), which remove not all but only specific elements contained in the plasma, and altogether allow to treat a large number of diseases.
Therapeutic Plasma Exchange
TPE
in case of
- Auto-immune diseases
- Rejection of transplanted organs
- Intoxication
TPE allows to remove patient’s plasma from the blood and to replace it with fluids which do not contain the large substances, such as antibodies, targeted to be removed. It applies to a wide range of acute diseases but more rarely to chronic ones due to the adverse effects of the replacement fluids, human albumin or fresh frozen plasma, overtime.
TPE is usually performed with 5-10 consecutive sessions of 1-2 hours.
Technically speaking
In TPE, blood is passed through a plasmafilter which allows plasma to be filtrated. The plasma is then discarded while a substitution fluid containing albumin is injected at the same rate, keeping the patient’s fluid and oncotic pressure balanced.
Cascade Filtration Double Filtration
DFPP
in case of
- Auto-immune diseases
- Rejection of transplanted organs
- Hypercholesterolemia
Like TPE, cascade filtration and DFPP allow to remove the larger substances from the blood, such as antibodies, fibrinogen or LDL-cholesterol. Its interest remains in the fact that the plasma is filtered and then returned to the patient, avoiding or minimizing the need for replacement fluids. Thus, cascade filtration/DFPP applies to both acute and chronic diseases.
In case of acute diseases, cascade filtration/DFPP is usually performed as TPE with 5-10 consecutive sessions of 1-2 hours, while for chronic diseases it is performed a few times per year depending on the underlying disease and patient’s situation.
Technically speaking
Cascade filtration is a 2 steps process during which plasma is first extracted from the blood and then circulated through a second filter named plasma fractionator having a pore size approximately 10 folds smaller than a plasmafilter, which retains the larger substances. While in cascade filtration the separation of plasma from blood can be obtained by centrifugation or filtration, in DFPP it is done by filtration only reason why the process can be named double filtration.
HP
Hemoperfusion
in case of
- Ulcerative colitis
- Crohn disease
- Inflammatory Mediator Removal
Hemoperfusion can be used to directly remove specific substances from the blood by adsorption, a technique which fixes substances on a surface. It is of particular interest for leukocytes which are too big to be filtrated without major loss of red cells.
Hemoperfusion can be used for both acute and chronic diseases, such as cascade filtration, and with the same frequency; 5 to 10 consecutive sessions of 1-2 hours.
Technically speaking
In hemoperfusion, blood is passed through a sorbent that retains the substances for which it is specifically designed. At the end of the treatment, the sorbent contains large amounts of this substance and is discarded. The sorbent directly interacts with the blood which is more prone to lead to some clinical side effects, such as bradykinine release, than plasma. Side effects and potential contraindications shall be pointed out by the manufacturer of such sorbent.
PP
PlasmaPerfusion
in case of
- Auto-immune diseases
- Rejection of transplanted organs
- Hypercholesterolemia
Plasmaperfusion allows to removes specific substances from the plasma by adsorption. It has on hemoperfusion the interest to lead to less side effects while compared to cascade filtration it is more specific for the targeted substances.
Plasmaperfusion can be used for both acute and chronic diseases, such as cascade filtration, and with the same frequency; 5 to 10 consecutive sessions of 1-2 hours.
Technically speaking
Plasmaperfusion is a 2 steps process during which plasma is first extracted from the blood and then circulated through a sorbent designed to retain some specific substances such as antibodies, Lp(a) or LDL cholesterol. The sorbent can be either single use and discarded at the end of the treatment or re-usable and regenerated after and/or during treatment.
Coupled Plasma Filtration Adsorption
CPFA
in case of
- Severe sepsis
- Septic shock
- Acute liver failure
CPFA is designed to remove some specific large substances by plasmaperfusion in-line with CVVH which replaces the kidney failure.
CPFA is performed according to the clinical situation, from 1 to 5 daily sessions.
Technically speaking
CPFA, is a 3 steps technic where first blood is passed through a plasmafilter, the obtained plasma being sent to a sorbent which retains some specific substances, such as cytokines or bilirubin, before returning the plasma to the blood. A hemofilter placed on the blood flow then allows to perform a hemofiltration which compensates for the kidney failure often associated to the main disease.
A bit ofHistory
Plasmatherapeutic procedures have been performed for the first time at the beginning of the 20th century and their application becomes really active during the 70’s all over the world.
The first plasmapheresis was performed in Russia in 1913 by Yurevitch and Rosenberg to demonstrate the concept of “ … washing the blood outside the body …”. It consisted in extracting a portion of the rabbits blood which was then centrifuged to separate the red blood cells. These were then mixed to normal saline which was heated before being reinjected to the rabbits.
However the term plasmapheresis was defined by Pr John Abel in USA in 1914, combining two terms :
- Plasma: liquid part of the blood
- Aphaeresis: In Greek “removal”
Thus, plasmapheresis was totally defined as a method of removal of plasma from an organism.
Unfortunately the First World War began which stopped the experiments and this technical approach was forgotten for a few decades.
In 1944, the Swedish physician Jan G. Waldenström described a case of Macroglobulinemia with symptoms of increased blood viscosity. In 1955, he performed effective plasmapheresis procedures on a patient with macroglobulinemia and noted an effective reduction of macroglobulin in the blood.
In 1963, several procedures were successfully performed on patients with Waldenström illness (Macroglobulinemia with high blood viscosity) which can be considered as the start of a regular application of plasmapheresis to a human disease.
Plasmapheresis is regularly performed in many countries since the 70’s with approximately 1000 procedures in England, 6200 in France and later in the 80’s with 50 000 procedures per year in the USA.
Today the term plasmapheresis includes different techniques (filtration or adsorption on plasma), which remove not all but only specific elements contained in the plasma, and altogether allow to treat a large number of diseases.
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