Therapeutic apheresis: use of human serum albumin, fresh frozen plasma and cryosupernatant plasma in therapeutic plasma exchange

doi:10.1016/j.beha.2005.01.004

Best Practice & Research Clinical Haematology

Volume 19, Issue 1, March 2006, Pages 157-167

https://doi.org/10.1016/j.beha.2005.01.004 Get rights and content

In therapeutic plasma exchange, patient plasma is removed and a colloid replacement solution is infused in its stead. A solution of 4–5% human serum albumin in saline is the recommended replacement solution in most instances, even though it leads to transient mild deficiencies of most plasma proteins. Albumin solutions are pasteurized to inactivate viruses, carry a very low risk of febrile and allergic reactions, and are convenient to store and administer. Fresh frozen plasma, which must be type specific and needs to be ordered in advance and thawed before use, carries a higher risk of reactions; however, it replaces all plasma constituents and is appropriate for patients with thrombotic thrombocytopenic purpura or a pre-existing coagulopathy. Neither cryosupernatant plasma, which is relatively depleted of the proteins in cryoprecipitate, nor pooled plasma that has been virally inactivated with organic solvents and detergents has been shown to be superior to fresh frozen plasma for any indication.

Section snippets

Human serum albumin

Between 70 and 80% of the oncotic activity in normal plasma is attributable to its albumin content, which averages 4.2 gm/dL.² In the United States, a 5% solution of purified human serum albumin in normal saline is widely available in 250 and 500 mL bottles containing, respectively, 12.5 and 25 g of human serum albumin. A 4% solution is available and preferred in some other countries.3, 4

Fresh frozen plasma

The product name ‘fresh frozen plasma’ refers to a single donor plasma product that is frozen within 8 hours after collection and stored at −18 °C or below. It contains all known coagulation factors in therapeutically useful quantities. Plasma that is frozen between 8 and 24 hours after collection, sometimes called ‘24-hour plasma’, contains comparable levels of all coagulation factors except factor VIII; its factor VIII content is adequate for normal coagulation.29, 30

Replacement of patient

Cryosupernatant plasma

The material that remains after cryoprecipitate has been removed from fresh frozen plasma is a defined plasma product (plasma cryoprecipitate reduced) that is often called cryosupernatant plasma.³⁷ It can be obtained from most blood suppliers. Cryosupernatant plasma is depleted of the constituents of cryoprecipitate, most notably the largest ‘normal’ vWF multimers. Prior to the discovery of the vWF-cleaving enzyme deficiency in thrombotic thrombocytopenic purpura, it was hypothesized that

Solvent/detergent plasma

Solvent/detergent plasma is pooled human plasma that has been treated with organic solvents and detergents to inactivate lipid-coated viruses, and then frozen in 200 mL aliquots.⁴⁰ Compared to fresh frozen plasma, solvent/detergent plasma is relatively deficient in certain inhibitory molecules–proteins C and S in the coagulation cascade, α2-antiplasmin and α1-antitrypsin. It contains the vWF cleaving protease but, like cryosupernatant plasma, is depleted of the largest ‘normal’ vWF multimers.

Summary

A 4–5% solution of human serum albumin in normal saline is the most commonly chosen replacement fluid for plasma exchange. This isotonic, iso-oncotic product offers unmatched viral safety and ease of administration combined with a very low risk of either febrile or allergic reactions. Fresh frozen plasma is an appropriate choice in thrombotic thrombocytopenic purpura and in other instances in which replenishing normal plasma proteins such as coagulation factors is deemed important. Neither

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Thawed plasma (TP) as a substitute for intravenous immune globulin (IVIG) to prevent hypogammaglobulinemia post-therapeutic plasma exchange
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Intravenous immune globulin (IVIG) is a common treatment given after plasma exchange procedures to either prevent secondary hypogammaglobulinemia or as an adjunctive treatment for organ transplant rejection. However, side-effects are relatively common with this medication during and after infusion. This case-report describes our alternative to IVIG infusions post-plasma exchange. We hypothesize that in patients unable to tolerate IVIG, using thawed plasma as a replacement fluid provides a suitable increase in the patients post procedure immunoglobulin G (IgG) levels for patients with secondary hypogammaglobulinemia that are unable to tolerate IVIG infusions.
Attenuation of age-elevated blood factors by repositioning plasmapheresis: A novel perspective and approach
2021, Transfusion and Apheresis Science
Aging is associated with the impairment of stem cell activation, leading to the functional decline of tissues and increasing the risk for age-associated diseases. The old, damaged or unrepaired tissues disturb distant tissue homeostasis by secreting factors into the circulation, which may not only serve as biomarkers for specific age-associated pathologies but also induce a variety of degenerative phenotypes. In this review, we summarize and discuss systemic determinants that perpetuate age-related tissue dysfunction. We further elaborate on the effects of attenuating these circulating factors by highlighting recent advances which utilize plasmapheresis in a pre-clinical or clinical setting. Overall, we postulate that repositioning therapeutic plasma exchange (TPE) to dilute the systemic factors, which become deleterious at their age-elevated levels, could be a rapidly effective rejuvenation therapy that recalibrates crucial signaling pathways to a youthful state.
Two cases of brand-specific albumin sensitivity in patients receiving regular therapeutic plasma exchange
2021, Transfusion and Apheresis Science
Citation Excerpt :
A crucial component of the procedure is the replacement of plasma with an equivalent volume largely composed of iso-oncotic fluid, to prevent hypotension or fluid imbalance following the procedure. A number of fluids are commonly utilized for this purpose including 4–5 % human albumin suspended in normal saline, normal saline, and donor plasma, each with their respective advantages and disadvantages [3]. The choice and relative quantity of each fluid further depends on the indication for PLEX as well as patient factors.
Therapeutic plasma exchange (PLEX) involves the removal of detrimental substances, commonly pathogenic antibodies or toxins, from a patient’s blood by exchanging their plasma with a replacement fluid. While a variety of replacement fluids are available, human albumin (4–5 %) is the most commonly used, as it is widely available, easily stored, and generally well tolerated. Despite its excellent safety profile, adverse reactions to albumin are well documented, ranging in severity from mild allergic symptoms to severe anaphylaxis. This report describes two cases of patients receiving frequent PLEX who developed sensitivities to human albumin. These patients differed substantially in the manifestations of their symptoms, the duration of their treatment, and their medical indication for PLEX. In both cases, symptom onset occurred shortly after completion of plasma exchange procedures and lasted for several hours. Symptoms disappeared when the patients were switched to albumin from a different manufacturer, suggesting that the reaction was specific to that formulation of albumin and not to the albumin itself. These cases highlight the possibility of manufacturer-specific acquired albumin sensitivities and provide a simple framework for the initial approach to the management of such reactions.
Albumin-based nanomaterials in drug delivery and biomedical applications
2021, Biopolymer-Based Nanomaterials in Drug Delivery and Biomedical Applications
Nanotechnology is advancing at a great pace and is being used for the treatment, prevention, and diagnosis of numerous ailments. Natural agents (drugs/polymers) are thought to be the best as they have greater biosafety, biodegradability, and negligible toxicity. Therefore, they are being investigated to make nanomaterials safer and eligible for clinical translation. Albumin, a globular protein, has been important in this regard owing to its properties like biocompatibility, biodegradability, nonimmunogenicity, nontoxicity, water solubility, cost-effectiveness, and tumor-targeting ability. Earlier albumin was used as a plasma volume expander but now it has emerged as a potential drug carrier and delivery vehicle. Albumin finds numerous applications as theranostic agents, biosensors, contrast agents, implants, etc. Albumin nanoparticles have been developed for targeting diseases like cancer, diabetes, arthritis, hepatitis C, etc. In this chapter, albumin, its types, binding ability, receptors, biomedical applications, albumin as a nanomaterial, its marketed formulations, and patents are discussed in detail.
Perioperative Applications of Therapeutic Plasma Exchange in Cardiac Surgery: A Narrative Review
2020, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
In patients with congenital TTP, routine TPE may not be required and these patients can be managed with serial plasma infusion when there is a congenital quantitative ADAMTS13 deficiency and no ADAMTS13 inhibitors.73 While 5% albumin is the most commonly used replacement fluid in many TPE applications, plasma is preferred in TTP because it contains ADAMTS13, which is deficient in TTP.15 Cryoprecipitate poor plasma may also be used in TTP and has the advantage of having minimal VWF content.
Therapeutic plasma exchange (TPE) has a number of applications in cardiac surgical patients and has been used increasingly in high-risk heart and lung transplant patients. In this narrative review, the authors describe TPE principles, complications, and specific indications for TPE, including thrombotic thrombocytopenic purpura, heparin-induced thrombocytopenia, induction of immunotolerance in heart and lung transplant patients, and treatment of antibody-mediated rejection in heart and lung transplant patients. The review is based on published literature and the authors’ institutional experience with perioperative TPE in cardiac surgical patients.
The use of emergency apheresis in the management of plasma cell disorders
2018, Transfusion and Apheresis Science
Citation Excerpt :
Experience with its effectiveness is limited and the cost is relatively high of price [8]. Because centrifugation based plasma separation provides bulk removal of plasma, anything circulating in plasma will be removed; a plasmapheresis procedure requires a replacement fluid [9]. The most commonly used replacement fluid is 4%–5% human albumin in physiologic saline.
Hyperviscosity syndrome (HVS) develops most commonly in Waldenström's macroglobulinemia (WM) and multiple myeloma (MM). Plasmapheresis is the immediate therapy and very effective at relieving symptoms by removing paraprotein. The most commonly used replacement fluid is 4%–5% human albumin in physiologic saline. FFP may be used in patients with coagulation abnormalities. Plasmapheresis should be continued until acute symptoms abate. Hyperviscosity impairs the circulation in the retina and causes hemorrhages around the small retinal vessels. Early diagnosis and urgent plasmapheresis may reduce blindness caused by retinal hemorrhages and/or retinal detachment. In HCV related mixed cryoglobulinemias, plasmapheresis is indicated if rapidly evolving life-threatening disease with immunosuppressive agent exists. In non-infectious mixed cryoglobulinemia plasmapheresis is indicated when the disease manifestations are severe, as a second line option. In WM patients with hyperviscosity symptoms and IgM > 4 g/dL, preemptive plasmapheresis is recommended to prevent an IgM flare with rituximab. Certain IgG/A MGUS-associated neuropathy patients may benefit from plasmapheresis. For cast nephropathy (suspected or biopsy proven), plasmapheresis is recommended when the sFLC ≥ 500 mg/l and as early as possible (<1 month with kidney injury). Theoretically, extracorporeal removal alone, without efficient tumor killing, could not reduce sFLC due to high production by the tumor mass and rapid rebound between compartments.

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11Therapeutic apheresis: use of human serum albumin, fresh frozen plasma and cryosupernatant plasma in therapeutic plasma exchange

Section snippets

Human serum albumin

Fresh frozen plasma

Cryosupernatant plasma

Solvent/detergent plasma

Summary

Br J Anaesth

Lancet

Transfus Apheresis Sci

Am J Med

Blood

Introduction to the third special issue: clinical applications of therapeutic apheresis

J Clin Apheresis

Albumin 1. Background and use

JAMA

Albumin products

Semin Thromb Hemost

Production of human albumin solutions: a continually developing colloid

Br J Anaesth

Protein and biochemical changes during plasma exchange

Basic principles of therapeutic blood exchange

Safety of human albumin as a constituent of biologic therapeutic products

Transfusion

The epidemiology of virus transmission by plasma derivatives: clinical studies verifying the lack of transmission of hepatitis B and C viruses and HIV type 1

Transfusion

Anaphylaxis to human serum albumin

Ann Allergy

Pyrogen reactions to human serum albumin in plasma exchange

J Clin Apheresis

Hemolysis and acute renal failure due to the administration of albumin diluted in sterile water

Transfusion

Human albumin administration in critically ill patients: systematic review of randomized controlled trials

Br Med J

Patient survival after human albumin administration: a mete-analysis of randomized, controlled trials

Ann Intern Med

For the SAFE study collaborators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit

N Engl J Med

Atypical reactions associated with the use of angiotensin-converting enzyme inhibitors with apheresis

Transfusion

11
Therapeutic apheresis: use of human serum albumin, fresh frozen plasma and cryosupernatant plasma in therapeutic plasma exchange