Rasheed A. Balogun

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice—Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Sixth Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence‐based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence‐based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149–162, 2016.

Guidelines on the use of therapeutic apheresis in clinical practice - Evidence-based approach from the writing committee of the american society for apheresis

The American Society for Apheresis (ASFA) JCA Special Issue Writing Committee is charged with reviewing, updating and categorizating indications for therapeutic apheresis. Beginning with the 2007 ASFA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence‐based approach in the grading and categorization of indications. This Sixth Edition of the ASFA Special Issue has further improved the process of using evidence‐based medicine in the recommendations by consistently applying the category and GRADE system definitions, but eliminating the “level of evidence” criteria (from the University HealthCare Consortium) utilized in prior editions given redundancy between GRADE and University HealthCare Consortium systems. The general layout and concept of a fact sheet that was utilized in the Fourth and Fifth Editions, has been largely maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. This article consists of 78 fact sheets (increased from 2010) for therapeutic indications in ASFA categories I through IV, with many diseases categorized having multiple clinical presentations/situations which are individually graded and categorized. J. Clin. Apheresis 28:145–284, 2013.

Introduction and overview of therapeutic apheresis

Chidi Okafor, David M. Ward, Michele H. Mokrzycki, Robert Weinstein, Pamela Clark, and Rasheed A. Balogun* Department of Medicine, Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia Department of Medicine, University of California, San Diego, California Department of Medicine, Albert Einstein College of Medicine, Bronx, New York Departments of Medicine and Pathology, University of Massachusetts, Amherst, Massachusetts Department of Pathology, University of Virginia, Charlottesville, Virginia

Falls in elderly hemodialysis patients

The elderly, (age ≥ 65 years) hemodialysis (HD) patient population is growing rapidly across the world. The risk of accidental falls is very high in this patient population due to multiple factors which include aging, underlying renal disease and adverse events associated with HD treatments. Falls, the most common cause of fatal injury among elderly, not only increase morbidity and mortality, but also increase costs to the health system. Prediction of falls and interventions to prevent or minimize fall risk and associated complications will be a major step in helping these patients as well as decreasing financial and social burdens. Thus, it is vital to learn how to approach this important problem. In this review, we will summarize the epidemiology, risk factors, pathophysiology and complications of falls in elderly HD patients. We will also focus on available methods to assess and predict the patients at higher risk of falling and will provide recommendations for interventions to reduce the occurrence of falls in this population.

Regional citrate anticoagulation in critically ill patients with liver and kidney failure.

BACKGROUND Regional citrate anticoagulation (RCA) is being used increasingly in critically ill patients who require continuous renal replacement therapy (CRRT). RCA may be avoided in patients with liver disease because of perceived increased risk of metabolic complications. The study compares the circuit lifespan and metabolic complications using RCA for CRRT at varying levels of liver dysfunction. METHODS Data was collected retrospectively including the number of days on CRRT, number of circuit (re)initiations within that time and serum ionized and total calcium, bicarbonate, and sodium, repeatedly during treatment. Model for end-stage liver disease (MELD) scores were calculated and patients were divided into 4 groups according to MELD score quartiles. RESULTS A total of 697 patients were included in the present study. The median circuit survival time was not different between groups. The median minimum serum ionized calcium levels during treatment were significantly lower in groups 3 and 4 (p<0.001), but by the last day of treatment, mean serum ionized calcium levels were not different between groups. The median minimum bicarbonate levels were significantly lower in groups 3 and 4 compared with groups 1 and 2 (p<0.01), but this is not considered clinically significant. The median maximum and mean serum bicarbonate levels were not significant between groups. Total to ionized calcium ratio levels were similar in groups 1, 2 and 3, but significantly higher in group 4 compared with other groups. CONCLUSION RCA is a reasonably safe form of anticoagulation for maintaining efficiency and patency of the dialyzer in critically ill patients with liver dysfunction.

Medications in Patients Treated With Therapeutic Plasma Exchange: Prescription Dosage, Timing, and Drug Overdose

Therapeutic plasma exchange (TPE) is an extracorporeal process commonly used in clinical medicine for the treatment of a variety of neurological, renal, hematological, dermatological, and other diseases. Inherent to the procedure, patients’ plasma removal may lead to the extraction of drugs they are concurrently receiving. This review discusses the published literature assessing TPE’s influence on different drug classes’ disposition and, when applicable, sets forth management recommendations in cases where the drugs are used at the usual doses and in cases of drug overdose.

Clinical applications of therapeutic apheresis

The vast majority of the renal indications for plasmaexchange are related to immunoglobulin removal.Immunoglobulins, especially IgG, have a relativelylong half-life. Thus in antibody-mediated disease, therecould be persistence of significant amounts of antibodyin the circulation despite cessation of antibody produc-tion. The aim of plasma exchange is to significantlyreduce circulating antibodies. Removal of the circulat-ing antibodies constitutes the rationale for using plas-mapheresis to treat antibody-associated glomeruloneph-ritis (GN). Although small molecular weight substancesare removed by plasma exchange, their large volumeof distribution and short half-lives make plasmaexchange an inefficient means of extracorporeal re-moval of these substances. For instance, some comple-ment proteins have a half-life of 2 days. If the goalwere to be to deplete plasma complement levels, virtu-ally daily plasma exchanges would be needed. Discon-tinuation of daily plasma exchange would be followedby rapid resurgence to normal complement titers.Hence the shorter the half-life of the molecule beingremoved, the more aggressive has to be the apheresisschedule.Plasma volume can be estimated using the followingformula:EPV ¼ 0:065 3 TBW 3 ½1 Hctwhere EPV is the estimated plasma volume, TBW isthe total body water, and Hct is hematocrit.The removal of large molecular weight substancesfrom the plasma compartment follows first-orderkinetics. Repetitive treatments should be spaced every24–48 h to allow for extravascular to intravascularequilibration.Apheresis has been used to treat several renal condi-tions including primary renal diseases as well as renalmanifestations of systemic conditions (Table I).

Therapeutic Apheresis: A Review of Complications and Recommendations for Prevention and Management

Therapeutic apheresis procedures are a form of extracorporeal therapy that use different techniques to separate blood into the different components out of which the part containing the etiological agent in a disease process is discarded and the rest of the components of blood are re‐infused into the patient, frequently with the addition of a replacement fluid or volume. These complex procedures have inherent risks of adverse events and factors that may impact on the incidence these events include the underlying disease state, anticoagulation techniques, replacement fluid type including the volume, issues related to the vascular access used, and the therapeutic apheresis procedure type and technique. We present a representative case based review of common complications of therapeutic apheresis and suggestions about how to prevent or manage these as presented at the 2010 Therapeutic Apheresis Academy. J. Clin. Apheresis, 2011.

Long-Term Morbidity and Mortality Related to Falls in Hemodialysis Patients: Role of Age and Gender – A Pilot Study

Background: Patients with end-stage renal disease (ESRD) on hemodialysis (HD) are prone to falls. In this pilot study, we aimed to determine the incidence of falls in a cohort of HD patients during a 1-year period, to identify any specific risk factors that may predict falls in this cohort, and to assess whether falls can independently predict hospitalization, nursing home admissions and/or mortality over an additional 2 years. Materials and Methods: Baseline assessments followed by documentation of falls prospectively during a 1-year period were done on 76 HD patients. Patients were followed for an additional 2 years and four outcomes were recorded: all-cause death, nursing home admission, the number and duration of all hospitalizations. Results: 20 patients (26.3%) fell over a 12-month period. Elderly and females had a higher risk of falls than the younger and male population (p = 0.034 and 0.006 respectively). During the 2-year follow-up, compared to non-fallers, fallers had a 2.13-fold increase in risk of death, a 3.5-fold increase in risk of nursing home admission, and nearly a 2-fold increase in the number and duration of hospitalizations. Conclusions: Falls are common in HD patients, with a higher incidence in females and elderly, and are associated with worse outcomes, more so in recurrent fallers.

Neurologic indications for therapeutic plasma exchange: 2013 update: Neurologic Indications for Therapeutic Plasma Exchange

Neurologists commonly use therapeutic plasma exchange (TPE) to treat a number of conditions. This concise review considers the most common neurologic indications for TPE. It focuses on Guillain–Barré syndrome and myasthenia gravis and also the role of TPE in chronic inflammatory demyelinating polyneuropathy, Lambert–Eaton syndrome, multiple sclerosis, neuromyelitis optica, paraproteinemic polyneuropathy, Sydenhams chorea, and natalizumab‐associated progressive multifocal leukoencephalopathy. As with any treatment, the proven efficacy, cost, side effects, and availability must be considered before initiation of therapy. J. Clin. Apheresis 29:211–219, 2014.