Therapeutic plasma exchange for hyperlipidemic pancreatitis:Current evidence and unmet needs

With changes in lifestyle and diet worldwide,the prevalence of hyperlipidemic acute pancreatitis(HLAP)has greatly increased,and it has become the most common cause of acute pancreatitis not due to gallstones or alcohol.There are many available therapies for HLAP,including oral lipid-lowering agents,intravenous insulin,heparin,and therapeutic plasmapheresis(TPE).It is believed that the risk and severity of HLAP increase with rising levels of serum triglycerides(TG),thus a rapid decrease in serum TG level is the key to the successful management of HLAP.TPE has emerged as an effective modality in rapidly reducing serum TG levels.However,due to its cost and accessibility,TPE remains poorly evaluated until now.Some studies revealed its efficacy in helping to treat and prevent the recurrence,while some studies suggested that TG levels were not correlated with disease severity,mortality,or length of hospital stay.Thus TPE might have no beneficial effect for the outcome.This article gives an overview of the published evidence of TPE in the treatment of HLAP and outlines current evidence regarding individual outcome predictors,adverse effects of the procedure,and TPE in special occasions such as for pregnant patients and patients with diabetic ketoacidosis.Future direction of TPE research for HLAP is also discussed in this review.

Therapeutic plasma exchange and continuous renal replacement therapy for severe hyperthyroidism and multi-organ failure:A case report

BACKGROUND Severe hyperthyroidism is a life-threatening exacerbation of thyrotoxicosis,characterized by high fever and multiorgan failure. The most common medical treatments are administration of antithyroid drugs and radioactive iodine, and thyroidectomy. In some patients, antithyroid therapy is limited due to serious adverse effects or failure to control disease progression. In some extreme cases,such as thyroid storm, conventional therapy alone does not yield effective and rapid improvement before the development of multiorgan failure.CASE SUMMARY This report describes a Chinese patient with severe hyperthyroidism accompanied by multiorgan failure, who was transferred to the medical intensive care unit of our hospital. The patient presented with palpitations, vomiting,diarrhea, and shortness of breath for a week. Laboratory tests showed elevation of thyroid hormones. Hepatic failure occurred with high aminotransferase levels and jaundice. Given her abnormal liver function and medication history, we could not exclude diagnosis of propylthiouracil-induced hepatic failure.Moreover, she also suffered from heart failure. Therapeutic plasma exchange(commonly known as TPE) and continuous renal replacement therapy(commonly known as CRRT) were used as life-saving therapy, which resulted in notable improvement of clinical symptoms and laboratory tests.CONCLUSION Combined TPE and CRRT are safe and effective for patients with hyperthyroidism and multiorgan failure.

Therapeutic plasma exchange in liver failure

The multi-organ failure syndrome associated with acute and acute-on-chronic liver failure(ACLF)is thought to be mediated by overwhelming systemic inflammation triggered by both microbial and non-microbial factors.Therapeutic plasma exchange(TPE)has been proven to be an efficacious therapy in autoimmune conditions and altered immunity,with more recent data supporting its use in the management of liver failure.Few therapies have been shown to improve survival in critically ill patients with liver failure who are not expected to survive until liver transplantation(LT),who are ineligible for LT or who have no access to LT.TPE has been shown to reduce the levels of inflammatory cytokines,modulate adaptive immunity with the potential to lessen the susceptibility to infections,and reduce the levels of albumin-bound and water-bound toxins in liver failure.In patients with acute liver failure,high volume TPE has been shown to reduce the vasopressor requirement and improve survival,particularly in patients not eligible for LT.Standard volume TPE has also been shown to reduce mortality in certain sub-populations of patients with ACLF.TPE may be most favorably employed as a bridge to LT in patients with ACLF.In this review,we discuss the efficacy and technical considerations of TPE in both acute and acute-on-chronic liver failure.

Integrated therapeutic plasma exchange and traditional Chinese medicine treatment in a patient with severe COVID-19:A case report

This report presents the case of a 59-year-old man with severe COVID-19 that gradually progressed to cytokine release syndrome and then acute respiratory distress syndrome;he was successfully treated via integration of therapeutic plasma exchange and traditional Chinese medicine.The patient initially presented with a sore throat,severe muscle aches,productive cough and fever.On the worsening of symptoms,remdesivir was administered.However,as the symptoms continued to worsen and a cytokine release syndrome was suspected,oxygen was provided through a high-flow nasal cannula(50 L/min)and therapeutic plasma exchange was performed to prevent worsening of the acute respiratory distress syndrome.On the same day,a course of traditional Chinese medicine was introduced in consultation with the infectious house staff.The patient’s symptoms gradually improved;the levels of C-reactive protein and D-dimers reduced,and the patient was weaned to a simple oxygen mask and eventually to room air.This is the first reported case of the integration of these treatments.Together,they prevented the patient from requiring intubation,played a role in cytokine management,and also improved the clinical symptoms,including productive purulent sputum,cough,frequent stool passage and intermittent fever,with no adverse effects.As a result,the patient was discharged within two weeks of the integration of these treatments.Therefore,the integration of therapeutic plasma exchange and traditional Chinese medicine is an effective therapy for patients with severe COVID-19.

Effects of therapeutic plasma exchange on survival in patients with postoperative liver failure:a retrospective single-center study

Background:Recent decreases in the incidence of postoperative liver failure(POLF)have been attributed to advances in surgical techniques,critical care,and postoperative management.However,POLF management remains a challenge,and worsening POLF is a significant cause of morbidity and mortality.Therapeutic plasma exchange(TPE)is used as a salvage strategy for POLF in some countries,and several studies conducted between 1980 and 1990 have reported the use of TPE for POLF.We conducted this retrospective single-center study to investigate the outcomes of patients with POLF treated with TPE.Methods:We retrospectively reviewed the charts of patients with POLF admitted to the intensive care unit who underwent TPE between November 2010 and March 2017.POLF was defined as the presence of persistent hyperbilirubinemia.Data on patient demographics,Glasgow Coma Scale score,platelet count,prothrombin time,and serum total bilirubin level were collected,and their Sequential Organ Failure Assessment scores were calculated.The lengths of postoperative hospital stays,lengths of post-TPE hospital stays,and patient outcomes were also analyzed.Results:TPE was performed in 20 patients with POLF during the study period.TPE was initiated on the 49th postoperative day and was performed for a median of five sessions.TPE improved hyperbilirubinemia and coagulopathy but had no effect on neurological and clinical symptoms.All 20 patients treated with TPE died after the 36th day(median)from the initial TPE.Conclusions:Although TPE may improve laboratory values in patients with POLF,the current study suggests that it has no survival benefit.

Diagnosis and management of fulminant Wilson's disease: a single center's experience

Background: Medical therapy is rarely effective inpatients with fulminant Wilson's disease (FWD). Livertransplantation is limited by the lack of donor liver inmost patients with FWD at the time of diagnosis. NewWilson's index, model for end-stage liver disease (MELD)and Child-Pugh score are useful tools for decisionmakingof liver transplantation;however, none of them isan independent decisive tool. It is worthwhile to explorea more effective and practical therapeutic strategy andreevaluate the prediction systems for patients with FWD.Methods: Nine patients with FWD associated withhemolytic crisis and fulminant hepatic failure (FHF) wereinvestigated. The clinical presentation, prognostic scoreand medical therapies of the patients were analyzed.Results: In 7 of the 9 patients with FWD who receivedthe comprehensive therapy of corticosteroid, copperchelatingagent (dimercaptopropansulfonate sodium)and therapeutic plasma exchange (TPE), 6 patientsrecovered from FHF. The remaining one had beenimproved through the comprehensive therapy but died ofsepticemia 51 days later. Two patients with spontaneousbacterial peritonitis (SBP) died from liver failure inthree or five hospital days without plasma exchangeor chelating therapy. All of the 9 patients with FWDpresented with acute hepatic failure, severe jaundice andmild to severe hemolytic anemia. No marked differencein the incidence of severe hemolytic anemia was detectedbetween the survival and deceased groups. However,the incidence and the degree of hepatic encephalopathy(HE) in the non-survival group were higher than thosein the survival group. Unlike the deceased group, thesurvival group had no complications induced by bacterialinfection. Compared to new Wilson's index, Child-Pughscore and MELD score, the variation of prothrombinactivity (PTA) between the survival and deceased groupswas more evident.Conclusions: For patients with FWD, the episodeof severe hepatic encephalopathy or/and spontaneousbacterial peritonitis indicates worse prognosis, andPTA is a recommendable predictor. An emergent livertransplantation should be considered for patients whosePTA is below 20%, or for those with severe HE or/and SBP. The comprehensive therapy of corticosteroid,copper-chelating agent and TPE is effective for patientswithout SBP and whose PTA is higher than 20%.