Role of therapeutic plasma exchange in acute humoral rejection patients undergoing live-related renal transplantation: A single-center experience.

BACKGROUND AND AIM: Renal transplantation (RT) is the most successful and ideal renal replacement therapy for end-stage renal disease patients. Renal allograft rejection has always been one of the major barriers in successful RT. Our aim was to report the role of therapeutic plasma exchange (TPE) in acute humoral rejection (AHR) patients who underwent live-related RT (LRRT) and their renal allograft outcome at our center. MATERIALS AND METHODS: A prospective observational study was conducted from July 1, 2014, to December 31, 2016. Patients with biopsy-proven AHR and treated with TPE along with other lines of treatment after undergoing LRRT were included in the study. ABO-incompatible individuals, pediatric patients, and patients undergoing second transplants were excluded from the study. Clinical history, donor and graft details, management, and patient and graft survival were noted. RESULTS: Of the 1608 patients who underwent LRRT, 49 (37 males, 76%; 12 females, 24%; mean age 39.5 ± 13.3 years) had biopsy-proven AHR (3.04%) and were treated with TPE. A total of 281 TPEs were performed with an average of 5.7 TPE/patient (range 2-12). Of the 49 patients, 38 patients (78%) with favorable response underwent 213 (75.8%) TPEs (average of 5.6 TPE/patient; range: 2-12), whereas 11 patients (22%) with unfavorable response underwent 68 (24.2%) TPEs (average of 6.2 TPE/patient; range: 3-8). Blood urea (P = 0.012) and serum creatinine (P = 0.038) levels at the time of rejection were significant predictors of response to TPE therapy. The average length of stay in our study population was 33 ± 22 days. Six months posttransplant, the patient and graft survival were 93.3% and 89.5%, whereas at 12 months, they were 89.3% and 81.5%, respectively. CONCLUSION: TPE is a safe and effective adjunct therapy for treating AHR patients.

Changes in pH and electrolytes during therapeutic plasma exchange in patients with liver diseases and factors predictive of these changes.

Therapeutic plasma exchange (TPE) disturbs the pH and electrolyte status. This study aimed to analyze the changes in pH, ionized calcium (iCa), sodium (Na), potassium (K), and bicarbonate (HCO3 ) of patients undergoing TPE and factors affecting these changes. The study included patients (age > 16 years) undergoing TPE from July 2016 to August 2017. Data on patient demographics, TPE procedures, pre-, and immediate post-TPE blood gas analysis values and adverse events during TPE were collected. A statistical analysis of the data was done to determine changes in pH and electrolytes and the factors affecting them. The changes in iCa, Na, and K due to the procedure were found to be statistically significant (P < .001). The changes in systolic (P = .010) and diastolic (P = .001) blood pressure during the procedure were significant. The predictors for the change in iCa were pre-procedure iCa (P < .001), age of the patient (P < .001), and the pre-procedure pH (P = .002). Complications related to hypocalcemia occurred in 12% of the TPE procedures. Hypocalcemic manifestations did not show any significant association with pre-procedure iCa levels, change in iCa levels during the procedure and age or gender of the patient. TPE induces marked changes in electrolytes but these changes are transient and do not warrant any intervention. The correction of iCa levels pre-TPE and continuous infusion of calcium during the procedure helps prevent marked fluctuations in iCa levels. This does not eliminate risks of hypocalcemia. Vigilance and preparedness to deal with complications related to hypocalcemia is the best strategy.

Therapeutic Immunoadsorption and Conventional Plasma Exchange in ABO-incompatible Renal Transplant: An Exculpatory Evidence.

Aim The objective of this study was to compare the efficacy of immunoadsorption (IA) with conventional therapeutic plasma-exchange (cTPE) in ABO-incompatible (ABOi) renal transplant. Methods Data of patients from July 2015 to June 2017 (category-I, number of patients (N) = 11; IA±cTPE) on the average length of stay (ALOS), number of cTPE/IA, antibody-titers (AT), creatinine, patient and graft survival at one year were compared retrospectively with patients in period from February 2012 to June 2015 (category-II, N = 29; cTPE only). AT of patients not decreasing to less than one fold after two cTPE were shifted for IA. For patients undergoing IA, real-time AT was done and IA stopped after target titer (TT <1:8) was achieved. Post-transplant cTPE was done if, titers rebounded to ≥1:8. Intravenous immunoglobulin (IVIG) was given after every cTPE/IA. Cost comparisons were made. Results In category-I, seven patients (63.63%) were shifted to IA from cTPE. The mean cTPE procedures in category I and II are 3.5 ± 2.4 and 4.8 ± 2.5, respectively (p = 0.206). The mean IA procedures in category-I are 1.6 ± 0.5. The number of patients requiring post-operative TPE was less in category-I than category-II, i.e., N = 5, 45.5% vs N = 20, 69%, respectively (p = 0.171). The expense of IA in category-I vs cTPE in category-II was statistically not significant (p = 0.422) but had significant lesser ALOS (p = 0.044). Expenses, when a patient undergoes both cTPE and IA (category-I), are significantly higher to category-II (p = 0.003). The two groups were comparable in AT, creatinine value, graft and patient survival rates at one year. Conclusion Contrary to the general judgment of IA being expensive than cTPE, this study shows equivalent expenditures with comparable therapeutic outcomes.

Comparative Evaluation of Five Different Methods of Anti-ABO Antibody Titration: An Aid for ABO-Incompatible Organ Transplants.

The accurate estimation of ABO antibody titers is of the utmost importance in organ transplants involving ABO incompatibility. We aim to compare five different methods of titration and analyze the data. Samples of 48 O group blood donors who donated during the month of December 2015 to January 2016 in our institution were subjected to ABO antibody titration by five different methods: immediate spin (IS) tube titer, antihuman globulin phase tube titer, Coomb's gel card titer, gel card titer after dithiotreitol (DTT) treatment of plasma, and the solid phase red cell adherence method. The mean number of titer serial dilution steps in the different titer estimation methods was compared using the paired t-test and McNemar test. A correlation between the methods was tested using Spearman's rho and kappa statistics. The median antiglobulin (AHG) phase tube titers were found to be the highest anti-A (128) and anti-B (192) titers. Significant differences in the ABO antibody titer readings among the five different methods were noted. Titers were reduced by DTT treatment in nearly 50% samples tested for both anti-A and anti-B titers. Average agreements between the DTT-applied AHG phase gel card titers and the solid phase red cell adherence (SPRCA) titers was observed for anti-A (κ = 0.473) and anti-B (κ = 0.530). The AHG phase tube and gel cards titers showed poor agreements. There are differences in the interpretability of the ABO antibody titer among different techniques. Consistent and uniform application of the method for titration throughout the treatment of a patient is highly essential.

Frequent plateletpheresis donations & its effect on haematological parameters: An observational study.

Background & objectives: The well-being of donors undergoing frequent plateletpheresis has been a matter of concern. The aim of this study was to analyze the effect of frequent plateletpheresis on the haematological parameters (HP) of repeat donors. Methods: The study was conducted during February 2016 to March 2017 on all the repeat plateletpheresis donors undergoing the 2nd plateletpheresis within a month of the first in a tertiary care centre. Donors repeating plateletpheresis 3rd and 4th times were also studied. The values of the HP observed on follow up after plateletpheresis done on three different separators were compared. Results: HPs of the 98 donors were similar at follow up except mean platelet volume (P <0.05). Of the 98 donors, 35 were followed up within a week and 63 were followed up within 8-30 days. No significant alteration was found in the HPs except a significant difference in the variation of platelet counts of the two groups (P=0.025). In 34 donors who presented 3rd time for plateletpheresis (mean gap between 1st and 3rd plateletpheresis=31 days), no significant differences in the HPs were found except the platelet distribution width (P <0.05). Minimal difference in the HP was found in the baseline and the follow up of 3rd plateletpheresis i.e., at 4th plateletpheresis donation. Plateletpheresis through all the three cell separators used had similar effects on the follow up HPs. Interpretation & conclusions: Repeated plateletpheresis can be done without any detrimental effects on the cell counts of the plateletpheresis donors. The three cell separators yielded similar post-donation follow up haematological parameters.

Facts and Fallacies of Kidd Antibodies: Experience in a Tertiary Care Hospital in North India.

We have analyzed the method used in our laboratory to detect the most elusive, clinically significant alloantibody: the Kidd alloantibodies and find the most convenient procedure. A retrospective analysis of the method used in our laboratory for determining Kidd alloantibodies from January 2013 to May 2015 was conducted. The details of the event that sensitized the patient for red cell antibody formation and procedure used to detect the alloantibody were retrieved from the departmental records. Of 405 red cell antibody identification cases, 24 (5.9 %) had Kidd antibody (anti-Jka in 12: 50 % cases; anti-Jkb in 4: 16.7 % cases; multiple antibodies in 8: 32 % cases). Thirteen of 24 patients (54.2 %) had autocontrol positive of which 6 cases needed adsorption procedures whereas antibody/ies could be identified without adsorption procedure in the remaining 7 cases. All the 7 cases had autocontrol of 1+ strength. Of the 11 patients (45.8 %) with autocontrol negative, the antibody was identified using solid phase in 7 cases whereas tube panels were also used in the remaining 4 cases. Kidd alloantibodies though deceptive can be identified by sensitive techniques like the solid phase and simple but laborious techniques using the tube cell panels. Depending upon the reaction strength of the autocontrol, the routine autoadsorption process may be skipped and tube cell enzyme treated cells or solid phase techniques be used to get the results.

ABO incompatible renal transplant: Transfusion medicine perspective.

INTRODUCTION: Our study presents an analysis of the trends of ABO antibody titers and the TPE (Therapeutic Plasma Exchange) procedures required pre and post ABO incompatible renal transplant. MATERIALS AND METHODS: Twenty nine patients underwent ABO incompatible renal transplant during the study period. The ABO antibody titers were done using the tube technique and titer reported was the dilution at which 1+ reaction was observed. The baseline titers of anti-A and anti-B antibodies were determined. The titer targeted was ≤8. Patients were subjected to 1 plasma volume exchange with 5% albumin and 2 units of AB group FFP (Fresh Frozen Plasma) in each sitting. TPE procedures post-transplant were decided on the basis of rising antibody titer with/ without graft dysfunction. RESULTS: The average number of TPE procedures required was 4-5 procedures/patient in the pretransplant and 2-3/patient in the post-transplant period. An average titer reduction of 1 serial dilution/procedure was noted for Anti-A and 1.1/procedure for Anti-B. Number of procedures required to reach the target titer was not significantly different for Anti-A and Anti-B (P = 0.98). Outcome of the transplant did not differ significantly by reducing titers to a level less than 8 (P = 0.32). The difference in the Anti-A and Anti-B titers at 14th day post-transplant was found to be clinically significant (P = 0.042). CONCLUSION: With an average of 4-5 TPE procedures pretransplant and 2-3 TPE procedures post transplants, ABO incompatible renal transplantations can be successfully accomplished.

Retrospective analysis of perioperative transfusion requirements in living donor renal transplantation.

BACKGROUND: Extensive bleeding in solid organ transplantation is a major challenge faced by transplant surgeons. Our aim was to audit the peri-operative transfusion requirements in our patients. MATERIALS AND METHODS: A retrospective analysis of living donor renal transplant surgeries performed from 1st May 2014 to 31st December 2014 was done. The blood/blood component usage during the peri-operative period was obtained. Univariate analysis was performed and the significant factors identified were further analyzed through multivariate regression analysis. RESULTS: A total of 510 patients (398 males: 78%, and 112 females: 22%) ranging from 18 to 77 years in age were included in the study. Of these, 269 (52.7%) patients were not transfused, while 241 (47.3%) patients received a total of 845 units of blood/blood components. The mean pre-operative hemoglobin in the transfused group was 8.7g/dl while in the non-transfused group it was 10.3g/dl. Leukoreduced packed red blood cell (PRBC) was the major blood component transfused during the peri-operative period. Multivariate regression analysis revealed that pre-operative hemoglobin was a major predictor of intra-operative PRBC transfusion (p = <0.001). Average post-operative length of stay (PLOS) was 10 ± 6 days. There was no significant difference in the PLOS between the transfused and non-transfused groups of patients; however, a statistical significant increase in utilization for both PRBC (p = 0.044) and fresh frozen plasma (p = 0.002) was observed with increased PLOS. CONCLUSION: Nearly 47.3% of patients undergoing living donor renal transplant received transfusion. PRBC was the most common product transfused and pre-operative hemoglobin was identified as strong predictor of blood consumption.