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Background and Objectives: In Japan, apheresis donation of plasma is allowed to a maximum of 24 times a year, and plateletpheresis are counted as two plasmapheresis donations. Diversion of the initial blood flow is conducted for all donations, and additionally, blood remaining in apheresis machine circuit is lost. Here, we aimed to investigate on the health impact of frequent apheresis donations, as measured by the serum ferritin (sFer). Materials and Methods: A total of 538 male apheresis donors and 538 age‐matched whole blood (WB) donors, who gave informed consent to join the study, were enrolled. sFer were compared, according to age. Another group of 19 apheresis donors were followed during four consecutive donations. Results: About half (48%) of repeat male apheresis donors had iron deficiency (sFer < 26 ng/mL), compared with lower rates (13.9%) among male WB donors. It was evident in all age groups, except for teenagers, possibly because of the lower number of donations. Follow‐up of the 19 donors for 4 months revealed a progressive decrease in sFer. Conclusion: Blood remaining in the apheresis machine circuit and diversion of the initial blood flow have been implicated in iron deficiency for many years. Taking the present results, the manufacturer of apheresis equipment was requested to improve it to allow rinseback of the remaining blood, which was achieved only for plateletpheresis. Until further improvement, plasmapheresis frequency was reduced to 12 times a year. Additional measures, such as oral supplementation of iron, need to be considered. [ABSTRACT FROM AUTHOR]

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe, adverse drug reaction that is notoriously complex in both its presentation and treatment. Although early diagnosis and cessation of the causative agent are universally accepted as the initial interventions for DRESS, the subsequent management lacks a standardized approach. Historically, systemic steroids have been used as first-line treatment, but there is debate about the optimal dosing and route of administration, and evidence persists on the long-term complications associated with steroid use. Novel treatment approaches with targeted therapy, cyclosporine, intravenous immunoglobulin, and plasmapheresis have been gaining interest as alternative mono- and adjuvant therapies, but their use has yet to be supported by clinical trials. This narrative review provides a summary of the current knowledge of DRESS, with a focus on clinical management. The various mono- and adjuvant therapy options are discussed, with literature-supported suggestions for their optimal use in clinical practice. The risks for relapses, viral reactivation, and long-term complications are also considered. The PubMed and Medline databases were searched for articles on DRESS, published between January 1, 2008, and May 1, 2023. 334 articles met the inclusion criteria. Based on the literature, a DRESS management tool with step-by-step guidance is provided. Further suggestions for management are woven throughout this review, giving clinicians a toolbelt of resources with which to approach diagnosis, treatment, and follow-up. [ABSTRACT FROM AUTHOR]

Background: Recurrence of focal segmental glomerulosclerosis (FSGS) or steroid-resistant nephrotic syndrome (SRNS) after kidney transplant leads to significant morbidity and potentially earlier allograft loss. To date however, reported rates, risk factors and treatment outcomes have varied widely. Methods: We applied computational phenotypes to a multicenter aggregation of electronic health records data from 7 large pediatric health systems in the USA, to identify recurrence rates, risk factors, and treatment outcomes. We refined the data collection by chart review. Results: From > 7 million patients, we compared children with primary FSGS/SRNS who received a kidney transplant between 2009 and 2020 and who either developed recurrence (n = 67/165; 40.6%) or did not (n = 98/165). Serum albumin level at time of transplant was significantly lower and recipient HLA DR7 presence was significantly higher in the recurrence group. By 36 months post-transplant, complete remission occurred in 58.2% and partial remission in 17.9%. Through 6 years post-transplant, no remission after recurrence was associated with an increased risk of allograft loss over time (p < 0.0001), but any remission showed similar allograft survival and function decline to those with no recurrence. Since treatments were used in non-random fashion, using spline curves and multivariable non-linear analyses, complete + partial remission chance was significantly higher with greater plasmapheresis sessions, CTLA4-Ig doses or LDL-apheresis sessions. Only treatment with anti-CD20, CTLA4-Ig agents, or LDL-apheresis sessions were associated with complete remission. Excluding 25 patients with mutations did not significantly change our results. Conclusions: Our contemporary high-risk cohort had higher favorable response rates than most prior reports, from combinations of agents. [ABSTRACT FROM AUTHOR]

Background: Coagulopathy is part of the pathological host response to infection in sepsis. Higher plasma concentrations of both tissue factor (TF) and tissue factor pathway inhibitor (TFPI) are associated with occurrence of disseminated intravascular coagulation (DIC), multi-organ dysfunction and increased mortality in patients with sepsis. Currently no treatment approaches specifically targeting this axis are available. We hypothesize that therapeutic plasma exchange (TPE) might limit this coagulopathy by restoring the balance of plasma proteins. Methods: This was a pooled post-hoc biobank analysis including 51 patients with early (shock onset < 24 h) and severe (norepinephrine dose > 0.4 μg/kg/min) septic shock, who were either receiving standard of care treatment (SOC, n = 14) or SOC + one single TPE (n = 37). Plasma concentrations of TF and TFPI were measured both at- and 6 h after study inclusion. The effect of TPE on concentrations of TF and TFPI was investigated and compared to SOC patients. Further, baseline TF and TFPI concentrations were used to modulate and predict clinical response to adjunctive TPE, indicated by longitudinal reduction of lactate concentrations over the first 24 h following study inclusion. Results: TPE led to a significant reduction in circulating concentrations of both TF and TFPI while no difference was observed in the SOC group. Relative change of TF within 6 h was + 14 (-0.8 to + 30.4) % (p = 0.089) in the SOC and −18.3 (−32.6 to −2.2) % (p < 0.001) in the TPE group (between group p < 0.001). Similarly, relative change of TFPI was + 14.4 (−2.3 to + 30.9) % (p = 0.076) in the SOC and −20 (−32.8 to −7.9) % (p < 0.001) in the TPE group (between group p = 0.022). The ratio of TF to TFPI remained unchanged in both SOC and TPE groups. SOC patients exhibited an increase in lactate over the initial 24 h when TF and TFPI concentrations were higher at baseline. In contrast, patients undergoing TPE experienced a sustained longitudinal reduction of lactate concentrations across all levels of baseline TF and TFPI elevations. In a multivariate mixed−effects model, higher baseline TF (p = 0.003) and TFPI (p = 0.053) levels led to greater longitudinal lactate concentration reduction effects in the TPE group. Conclusions: Adjunctive TPE in septic shock is associated with a significant removal of both TF and TFPI, which may contribute to the early hemodynamic improvement observed in septic shock patients receiving TPE. Higher baseline TF (and TFPI) plasma concentrations were identified as a putative predictor of treatment response that could be useful for predictive enrichment strategies in future clinical trials. [ABSTRACT FROM AUTHOR]

The virus SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) causes COVID-19, a potentially fatal disease. The COVID-19 vaccine is indicated for active immunization to prevent COVID-19 caused by SARS-CoV-2. We reported the case of a 66-year-old woman with a medical history of hypertension and anxious-depressive syndrome who developed Guillain Barré Syndrome (GBS) 4 weeks after receiving the COVID-19 vaccine. During the patient's hospital stay, they received cycles of high-dose intravenous immunoglobulin (IVIG) and plasmapheresis treatments.. Despite the treatment, a deterioration of respiratory function led the patient to premature mortality. [ABSTRACT FROM AUTHOR]

Introduction: Myasthenia gravis is an autoimmune disease that is charecterized by production of acetyl cholinesterase receptor auto antibodies. This is a retrospective study done in 45 patients who were offered trans-sternal thymectomy in such patients. Objectives: Adequate pre operative preparation with immunosuppressive agents and myasthenia gravis modifying drugs, plasmapheresis before surgery helps optimize out comes. Material and methods:Retrospectively data was collected from the years 2017-2020 in 45 patients who underwent trans-sternal thymectomy for myasthenia gravis and results analysed. Results: There has been no mortality noted in this study. 13 patients needed post operative management of myasthenic crisis. There was no reduction in the dosage of pyridostigmine. However, there has been a significant reduction in the dosage of steroids and azathriopine. Conclusion: Presence of thymoma, positive AChR Antibodies, moderate to severe airway disease are significant predictors of perioperative crisis. Prior adequate optimization before surgery is of utmost importance to prevent postoperative myasthenia crisis. Thymectomy is a very safe and effective procedure. [ABSTRACT FROM AUTHOR]

Homozygous familial hypercholesterolemia (HoFH), is a rare genetic disorder characterized by dual mutations in the low-density lipoprotein receptor (LDLR) gene, leading to dysfunctional or absent LDLRs, often accompanied by severe premature Atherosclerotic Cardiovascular Disease (ASCVD) and exhibiting refractoriness to aggressive pharmacological interventions. Double filtration plasmapheresis (DFPP), a form of lipoprotein apheresis (LA), has been effectively utilized as an adjunctive treatment modality to reduce serum LDL-C levels in refractory cases of HoFH. Here, we report a case of a 36-year-old female with HoFH who developed xanthomas on her limbs and waist at age 7. Despite maximum-tolerated doses of statins from age 32, combined with ezetimibe and evolocumab, her LDL-C levels remained critically elevated at 12–14 mmol/L. Her genetic testing confirmed a homozygous LDLR mutation. At 35 years old, she experienced exertional chest pain, and percutaneous coronary intervention revealed severe calcific left main stenosis, necessitating stent implantation. Subsequently, she initiated once every 1–2 months DFPP. Pre-DFPP, her LDL-C and total cholesterol (TC) levels were 13.82 ± 3.28 and 15.45 ± 0.78 mmol/L, respectively. Post-DFPP, her LDL-C and TC levels significantly decreased to 2.43 ± 0.33 mmol/L (81.76 ± 4.11% reduction) and 3.59 ± 0.41 mmol/L (76.76 ± 2.75% reduction), respectively. Lipoprotein (a) and triglycerides also decreased by 89.10 ± 1.39% and 42.29 ± 15.68%,respectively. Two years later, there was no progression of coronary artery disease, and her symptoms and xanthomas regressed significantly. Collectively, DFPP effectively reduces LDL-C levels in refractory cases of HoFH and contributes to delaying ASCVD progression, representing an efficacious adjunctive therapeutic modality. [ABSTRACT FROM AUTHOR]

Introduction: Acute hypertriglyceridemia is considered a category III indication for plasmapheresis. The use of plasma as replacement fluid (RF) has been suggested to replace the consumed lipoprotein lipase. Heparin when used as an anticoagulant could possibly release lipoprotein lipase, thereby increasing triglyceride clearance. Methods: The impact of RF (albumin vs fresh frozen plasma (FFP) and anticoagulant (ACD‐A vs. heparin) on triglycerides following plasmapheresis in 27 patients with severe hypertriglyceridemia (SHTG) was investigated. A paired study of four patients with recurrent SHTG was conducted, evaluating continuous (Optia) versus intermittent flow plasmapheresis (Haemonetics). Results: Shorter procedures positively impacted triglycerides (TG) drop post‐sessions p < 0.05. In albumin sessions, patients who used heparin demonstrated significantly greater drop in TG and required less sessions than did those with citrate p < 0.05. In heparin sessions, patients who used albumin demonstrated significantly greater drop in triglycerides and required less sessions than did those with FFP p < 0.05. Three of six patients who used FFP and heparin showed a triglyceride drop of 11.7% following three sessions and a 50% drop with one albumin session. Compared with Haemonetics, Optia removed comparable volumes of plasma in less time, processing smaller blood volumes and using less citrate p < 0.05. Patients demonstrated significantly lower drop in TG and required more sessions with Haemonetics than they did with Optia p < 0.05. Conclusion: Shorter procedure was the main predictor for effective TG clearance. This can be achieved by continuous apheresis technology, particularly when using albumin as RF. TG removal via Optia seems to be optimized by using heparin. [ABSTRACT FROM AUTHOR]

Simple Summary: Recently, CMTM6 has been found to stabilize PD-L1 on the plasma membrane of some tumor cells, favoring tumor immune system evasion. Until the present, it was unknown whether this protein could be present in a soluble form in the plasma of patients with cervical cancer (CC) or, additionally, if it could be found in atypical subcellular compartments in cell lines derived from CC. The results of our present research confirm that CMTM6 is increased in the plasma of patients with CC and associated, but not exclusively so, with exosomes, and that exosomal CMTM6 levels are correlated with exosomal PD-L1 levels. In addition, in CC cell lines, CMTM6 was found to be secreted and present both on the membrane and intracellularly. CMTM6 derived from CC in soluble, exosomal membrane and intracellular forms could have an impact on the biology of tumor cells by affecting the expression of molecules associated with tumor development and progression, such as PD-L1. CMTM6 is a membrane protein that acts as a regulator of PD-L1, maintaining its expression on the cell surface, and can prevent its lysosome-mediated degradation. It is unknown if CMTM6 is present in the plasma of patients with cervical cancer, and if it has non-canonical subcellular localizations in cell lines derived from cervical cancer. Our objective was to determine whether CMTM6 is found in plasma derived from cervical cancer patients and its subcellular localization in cell lines. Patient plasma was separated into exosome-enriched, exosome-free, and total plasma fractions. The levels of CMTM6 in each fraction were determined using ELISA and Western blot. Finally, for the cellular model, HeLa, SiHa, CaSki, and HaCaT were used; the subcellular locations of CMTM6 were determined using immunofluorescence and flow cytometry. Soluble CMTM6 was found to be elevated in plasma from patients with cervical cancer, with a nearly three-fold increase in patients (966.27 pg/mL in patients vs. 363.54 pg/mL in controls). CMTM6 was preferentially, but not exclusively, found in the exosome-enriched plasma fraction, and was positively correlated with exosomal PD-L1; CMTM6 was identified in the membrane, intracellular compartments, and culture supernatant of the cell lines. These results highlight that CMTM6, in its various presentations, may play an important role in the biology of tumor cells and in immune system evasion. [ABSTRACT FROM AUTHOR]

Catatrophic antiphospholipid syndrome (CAPS), a rare variant of antiphospholipid syndrome (APS), is associated with rapid multiorgan failure. While APS is associated with single medium-to-large blood vessel occlusions, CAPS is most often associated with several, concurrent vascular occlusions of small vessels, commonly of the kidneys, heart, skin and brain. We present a case of a 21-year-old female patient with a history of immune thrombocytopenia purpura and APS, who eventually developed concurrent cerebral venous sinus thrombosis, diffuse alveolar haemorrhage, renal thrombotic microangiopathy, and a necrotic, vasculitic wound on her forearm. Despite hospitalisation and treatment, her condition worsened and the patient eventually died after succumbing to suspected CAPS. [ABSTRACT FROM AUTHOR]

Background and Objectives: Tattooing is one of the leading donor deferral reasons in Australia. Until September 2020, donors were deferred from all donation types for 4 months after a tattoo. At this time, our guideline changed such that donations of plasma for further manufacture were accepted immediately, provided the tattoo was administered in a licensed or regulated Australian establishment. We examined the effects of this change. Materials and Methods: Donors with a tattoo deferral in the 2 years before or after the guideline change were identified and followed up until 3 November 2022. Between the two periods, we compared blood‐borne virus (BBV) incidence, donor return, and the number of donors and donations regained after deferral. Results: The incidence of BBV infection in donors after a tattoo deferral was zero in both periods. To exceed a residual risk of 1 in 1 million for hepatitis C virus, 190 donors would need to be infected yearly from a tattoo. Donors returned to donate significantly faster after the change (median return 85 days compared with 278 days). An extra 187 donations per 10,000 person‐years of observation were gained, yielding a total of 44,674 additional plasma donations nationally 0–4 months after getting a tattoo. Conclusion: Allowing plasma donations immediately post‐tattoo resulted in a substantial donation gain with no adverse safety effect. Lifeblood subsequently reduced the deferral for transfusible component donations to 7 days for tattoos in Australian licensed/regulated establishments. [ABSTRACT FROM AUTHOR]

Background and objectives: Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an acquired treatable autoimmune disorder. Due to limited availability and affordability of IV immunoglobulins and therapeutic plasma exchange in Pakistan, oral immunosuppressive drugs (ISDs) are used despite limited role in literature. The study aimed to determine the response to ISDs in CIDP patients by assessing the frequency of remission, reduction of disability using a neuropathy related disability score called Inflammatory Neuropathy Cause and Treatment score (or INCAT score), as well as reduction in steroid maintenance dose. Methods: The retrospective observational study of six months duration (May to October, 2020) was carried out in Aga Khan University Hospital, Karachi, Pakistan. Medical record of all the patients with idiopathic CIDP taking oral ISDs in last five years was selected which included bio-data, clinical signs and symptoms, medication details, and INCAT scores. Descriptive statistics were described i.e. frequency, percentages, mean/standard deviation using Microsoft Excel v.2021. Results: Out of thirteen patients, Azathioprine was used in nine, Mycophenolate mofetil in two and Cyclosporine in two, with remission (INCAT score improvement ≥ 1) achieved in eight, one and zero patients respectively. Duration of ISDs ranged from three to twenty-four months (average 15.8 months). Patients with monoclonal paraproteinemia and prior exposure to ISDs had a poor response to the introduction of subsequent ISDs. Conclusion: The study describes preliminary experience of the potential role of relatively cheaper and more convenient oral ISDs (especially Azathioprine) as an alternative or sparing agent to first line agents for CIDP and sets the stage for larger scale studies and randomized controlled trials. [ABSTRACT FROM AUTHOR]

Copyright of Die Nephrologie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Medizinische Klinik: Intensivmedizin & Notfallmedizin is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract Focal segmental glomerulosclerosis (FSGS) is a major cause of pediatric kidney failure. Most cases of FSGS in children are idiopathic and have a high risk of post-transplantation recurrence and graft loss. Common treatments for recurrent FSGS (rFSGS) post-transplantation include plasmapheresis, immunoadsorption, and/or immunomodulatory therapy. This study retrospectively evaluated the efficacy and safety of early plasmapheresis followed by rituximab for inducing and maintaining remission in rFSGS. Between 2014 and 2023, 8 of 65 pediatric kidney transplant recipients at our center were diagnosed with idiopathic FSGS. rFSGS was diagnosed based on nephrotic range proteinuria with no other cause and managed with plasmapheresis. Rituximab therapy was used for those who did not achieve complete remission with prolonged plasmapheresis or remained plasmapheresis dependent. 6 of 8 (75%) transplant recipients with idiopathic FSGS experienced rFSGS. All patients achieved partial or complete remission with plasmapheresis, with response times ranging from 8 to 379 days (median 13 days). Rituximab therapy was introduced for 5 plasmapheresis-dependent patients, leading to sustained remission and cessation of plasmapheresis in 3 patients, while 2 showed improved proteinuria and reduced plasmapheresis frequency. Adverse effects included rituximab-induced serum sickness in one patient and one mild allergic reaction. One patient experienced graft loss due to humoral rejection, but no grafts were lost to rFSGS, and all other grafts remained functional over an average follow-up of 50 months. Early plasmapheresis followed by rituximab therapy effectively induces remission in most post-transplantation rFSGS cases, is well tolerated, and prevents graft loss. Larger studies are needed to confirm these findings.

Neuromyelitis optica spectrum disorder (NMOSD), also known as “Devic's syndrome”, is an autoimmune demyelination disorder. It affects the optic nerve and spinal cord, causing optic neuritis and transverse myelitis. It is associated with anti-aquaporin 4 antibodies that target the aquaporin channel on astrocytes. An 18-year-old male with a history of appendectomy 6 months ago presented with neck pain, numbness in limbs up to the umbilicus, paresis, and spasticity in the left leg. The brain magnetic resonance imaging (MRI) was normal, while the spinal cord MRI showed hyperintense foci at the T2 level. Cerebrospinal fluid (CSF) analysis was in the normal range and negative for oligoclonal bands. The serological assay was positive for anti-aquaporin-4 antibodies (AQP4-IgG). The patient improved significantly after administering high doses of methylprednisolone and supplements. Due to the unavailability of eculizumab, he underwent plasmapheresis sessions to remove antibodies, which improved to a reasonable extent. NMOSD most commonly targets older females, but in our report, it appeared in a young male. The patient only presented with transverse myelitis with no ophthalmologic problem. He made significant improvement with combination treatment of steroids, supplements, and plasmapheresis.

As no unified treatment protocol or evidence yet exists for plasmapheresis without plasma, this study explored the outcomes of using 4% human albumin (ALB) solution as a replacement solution in patients undergoing plasma exchange for multiple myeloma (MM) patients with acute kidney injury (AKI). This study was prospectively registered (ChiCTR2000030640 and NCT05251896). Bortezomib-based chemotherapy plus therapeutic plasmapheresis (TPP) with 4% human ALB solution was assessed for three years in patients with MM aged >18 years, with AKI according to the Kidney Disease Improving Global Outcomes criteria, and without previous renal impairment from other causes. The primary endpoints were changes in renal function over 18 weeks and survival outcomes at 36 months. The secondary endpoints were the incidence of adverse reactions and symptom improvement. Among the 119 patients included in the analysis, 108 experienced renal reactions. The M protein (absolute changes: median −12.12%, interquartile ranges (IQRs) −18.62 to −5.626) and creatine (median −46.91 μmol/L, IQR −64.70 to −29.12) levels decreased, whereas the estimated glomerular filtration rate (eGFR) increased (median 20.66 mL/(min·1.73 m2), IQR 16.03–25.29). Regarding patient survival, 68.1% and 35.3% of patients survived for >12 and >36 months, respectively. The three symptoms with the greatest relief were urine foam, poor appetite, and blurred vision. All 11 patients (7.6%) who experienced mild adverse reactions achieved remission. In conclusion, in MM patients with AKI, plasma-free plasmapheresis with 4% human ALB solution and bortezomib-based chemotherapy effectively alleviated light chain damage to kidney function while improving patient quality of life. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this paper is to summarize the blood purification technology applied in patients with severe fever with thrombocytopenia syndrome (SFTS) in the clinical treatment effect. Methods: The medical records of 96 patients with severe SFTS admitted to Weihai Municipal Hospital affiliated to Shandong University from May 2014 to November 2019 were retrospectively analyzed, and they were divided into survival group and death group. The differences in basic data test indexes and treatment method selection during intensive care unit (ICU) admission between the two groups were significantly analyzed, and the indexes with statistically significant differences were included in the multivariate logistic regression analysis related to prognosis. Results: There were no statistically significant differences in age, sex composition, white blood cell count, platelet count, creatine kinase (CK), activated partial thromboplastin time (APTT), serum creatinine and hemofiltration renal replacement therapy between the survival group and the death group. There were statistically significant differences between the two groups in viral load bilirubin and the treatment methods of plasma exchange (PE) or hemoperfusion (HP). Plasma exchange group (78 cases), hemofiltration group (12 cases), hemoperfusion group (6 cases), plasma exchange and hemoperfusion and other blood purification treatment of the prognosis were statistically different. Conclusions: Compared with the three blood purification methods, plasmapheresis has a significant effect on virus removal, improvement of coagulation function and survival rate in patients with severe SFTS. Hemofiltration plays a role in removing inflammatory mediators, replacing renal function, maintaining electrolytes and acid-base balance, but not in removing viruses. [ABSTRACT FROM AUTHOR]

Introduction: Therapeutic plasma exchange (TPE) eliminates disease‐contributing substances but may also affect drug concentrations. This study aimed to assess the prevalence of prescription drugs removable via TPE by reviewing patient medication histories. Methods: A retrospective, single‐center study was conducted from January 1, 2021 to December 31, 2022. The study included 244 patients undergoing 1087 TPE sessions. Drugs prescribed to patients on TPE days were categorized as "yes" (probably removable), "maybe" (possibly removable), and "no" (unlikely removable) regarding their removability via TPE. Results: Among 3966 prescriptions, 556 (14.0%) were analyzed, with 21.8%, 36.5%, and 41.7% falling into the "yes," "maybe," and "no" categories for removability. Although only 14.0% were categorized, 83.6% of patients received at least one analyzable drug. Among them, 83.8% had at least one potentially removable drug. Conclusion: Real‐world data highlights the need for caution in drug treatments during TPE to ensure optimal therapeutic outcomes, particularly for specific drugs. [ABSTRACT FROM AUTHOR]

Double filtration plasmapheresis (DFPP) is a semi‐selective blood purification modality derived from the plasma exchange modality. DFPP can be applied to a variety of refractory disorders including metabolic disorders, organ transplants, rheumatic disorders, neurological disorders, and dermatologic disorders. Familial hypercholesterolemia and lipoprotein (a) hyperlipoproteinemia are major chronic metabolic disorders. Lipoprotein apheresis (LA) is applied for those patients to remove low‐density lipoprotein cholesterol (LDL‐C) and lipoprotein (a) (Lp(a)). DFPP is used as one of the modalities in LA. In addition to removing LDL‐C and Lp(a), DFPP has pleiotropic effects such as removal of lipid metabolism‐related substances, C‐reactive protein lowering effect, removal of adhesion molecules, removal of inflammatory cytokines, and anti‐oxidative effect. This article summarizes the pleiotropic effects of DFPP based on recent clinical articles. [ABSTRACT FROM AUTHOR]

Thyroid storm is a rare, life-threatening endocrine emergency characterized by severe clinical manifestations of thyrotoxicosis. Studies in the United States and Japan show that the annual incidence rates of hyperthyroid storm are (0.57-0.76) per 100 000 people and 0.2/100 000 people, respectively, accounting for 0.22% of all hyperthyroid patients and 5.4% of hospitalized hyperthyroid patients. Even with timely treatment, the mortality rate of patients with hyperthyroidism storm is still as high as 10%-30%; If left untreated, the mortality rate of patients may reach 90%. The misdiagnosis and missed diagnosis rate of hyperthyroidism storm in the Emergency Department is as high as 43.48%. It may be precipitated by abrupt discontinuation of antithyroid drugs or by an acute event such as infection, trauma, thyroid or nonthyroidal surgery, an acute iodine load, or parturition and other rare causes. There are currently no recognized standards or validated clinical tools for diagnosing thyroid storm. The diagnosis of thyroid storm is based upon the presence of biochemical evidence of hyperthyroidism (elevation of free T4 and/or T3 and suppression of TSH), and severe and life-threatening symptoms (hyperpyrexia, cardiovascular dysfunction, and altered mentation). BWPS has been widely used for the identification of thyroid storm for nearly 30 years. The main treatments for thyroid storm consist of symptomatic treatment and specific treatment for the thyroid gland, including removing the cause and treating complications cuse of thionamide, iodine, glucocorticoids and beta-blockers to inhibit new hormone synthesis, block the peripheral conversion of T4 to T3, inhibition of the release of thyroid hormone. If the above treatment do not improve the condition, blood purification therapy (plasmapheresis) can be tried. In addition to specific therapy directed against the thyroid, supportive therapy is essential. After active treatment, most of the status of patients with thyroid storm are improved within 1 to 2 days. After a successful rescue of thyroid storm, hyperthyroidism should be treated by radical treatment.

The paper presents a description of a clinical case of Gougerot–Hailey–Hailey disease with proven dysregulation of the immune response. The disease, also known as chronic benign familial pemphigus, is a rare genetic disorder that causes bullous skin lesions with intraepidermal localization. It is named after the authors who first described it. In most cases, Gougerot–Hailey–Hailey disease is caused by a mutation in the ATP2C1 gene that disrupts calcium regulation. Calcium accumulation alters normal intercellular adhesion in the skin, resulting in characteristic bullous skin lesions. Gougerot–Hailey–Hailey disease is inherited in an autosomal dominant pattern. The frequency of distribution in the population is 1:50000 people. However, the variety of clinical phenotypes of the disease without a proven hereditary predisposition and the absence of a mutation in this gene allows us to assert the presence of other pathogenic factors, in particular, disorders in the immune system. In the clinical case we are describing, no clear genetic predisposition was revealed, but serious disorders in the immune system were detected. In particular, TNK cells are virtually non-existent. Analysis of subpopulations of natural killer cells indicates a decrease in the relative and absolute numbers of NK cells expressing CD16 and CD56 antigens, NK cells with high cytolytic activity, NK cells expressing the α chain of the CD8 antigen and having the ability to repeatedly perform their cytolytic function. When assessing B cell subpopulations, there is an increase in the relative content of B2 cells and B1 cells associated with production of autoantibodies, in parallel with an increase in the percentage of regulatory T helper cells with immunosuppressive function. Based on the identified changes in the immune system, we performed immunomodulatory therapy: discrete plasmapheresis, 5 procedures in 2 days, then intravenous drip injection of normal human immunoglobulin 25 mL (50 μg/mL) in 3 days, 5 infusions. The dynamics of cutaneous manifestations indicates a moderate positive effect. Obviously, further in-depth study of immune parameters in Gugerout-Haley-Haley disease, presumably in the innate immune system, is required. Probably, success in treatment and achievement of stable remission will be possible with the rational selection of anticytokine therapy.

Background & Aim: Hypotension is a common complication associated with plasmapheresis. Elevating the legs and using elastic stockings are nursing interventions aimed at preventing hypotension. The objective of this study was to compare the effects of elastic stockings and leg elevation on the prevention of hypotension during plasmapheresis. Methods & Materials: This randomized crossover clinical trial was conducted on 35 patients undergoing plasmapheresis at Beheshti Hospital in Hamadan from 2020 to 2021. Patients were selected based on convenience sampling and then allocated to four different methods in four sessions using random permuted block designs: elastic stockings (A), leg elevation (B), a combination of elastic stockings and leg elevation (C), and a control group (D). Blood pressure was monitored before, during (every half hour), and half an hour after the completion of plasmapheresis. Data analysis was performed using SPSS version 24, applying repeated measures ANOVA with a significance level of 0.05. Results: During plasmapheresis, systolic blood pressure decreased over time in all four methods (P

Peripheral neuropathy is a prevalent complication in plasma cell disorders, posing significant diagnostic and therapeutic challenges. This study presents three cases initially diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP). Despite initial symptom regression post-immunomodulatory treatment, the patients exhibited progressive neurological deficits. Advanced laboratory evaluation confirmed monoclonal protein presence, yet traditional diagnostic methods, including bone marrow biopsy and flow cytometry, yielded normal results. Utilizing 18F-FDG PET/CT, we identified multiple hypermetabolic vertebral lesions, which upon biopsy, confirmed the diagnosis of plasmacytoma. Our findings underscore the utility of PET/CT as a reliable diagnostic tool for monoclonal gammopathy associated neuropathy, advocating for its consideration in cases with equivocal diagnosis. When the diagnosis is in doubt, biopsy of a lesion may facilitate early and accurate diagnosis, potentially influencing treatment strategies and patient outcomes. [ABSTRACT FROM AUTHOR]

Purpose: Nowadays, it is largely accepted that albumin should not be used in hypoalbuminemia or for nutritional purpose. The most discussed indication of albumin at present is the resuscitation in shock states, especially distributive shocks such as septic shock. The main evidence-based indication is also liver disease. In this review, we provided updated evidence-based instruction for definite and potential indications of albumin administration in clinical practice, with appropriate dosing and duration. Methods: Data collection was carried out until November 2023 by search of electronic databases including PubMed, Google Scholar, Scopus, and Web of Science. GRADE system has been used to determine the quality of evidence and strength of recommendations for each albumin indication. Results: A total of 165 relevant studies were included in this review. Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, have a moderate to high quality of evidence and a strong recommendation for administering albumin. Moreover, albumin is used as a second-line and adjunctive to crystalloids for fluid resuscitation in hypovolemic shock, sepsis and septic shock, severe burns, toxic epidermal necrolysis, intradialytic hypotension, ovarian hyperstimulation syndrome, major surgery, non-traumatic brain injury, extracorporeal membrane oxygenation, acute respiratory distress syndrome, and severe and refractory edema with hypoalbuminemia has a low to moderate quality of evidence and weak recommendation to use. Also, in modest volume paracentesis, severe hyponatremia in cirrhosis has a low to moderate quality of evidence and a weak recommendation. Conclusion: Albumin administration is most indicated in management of cirrhosis complications. Fluid resuscitation or treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments, is another rational use for albumin. Implementation of evidence-based guidelines in hospitals can be an effective measure to reduce inappropriate uses of albumin. [ABSTRACT FROM AUTHOR]

This report details the case of a 51‐year‐old man with a Tiger snake bite who developed systemic envenomation, coagulopathy and thrombotic microangiopathy (TMA) requiring renal replacement therapy. He received plasma exchange as additional therapy while awaiting confirmation of the cause of the TMA. We discuss clinical decision making in detection of systemic envenomation and management of the rare complication of TMA, as well as current Australian guidelines around antivenom administration. This is the fourth known documented case of TMA from a Tiger snake bite in Australia. [ABSTRACT FROM AUTHOR]

Introduction: Rituximab (RTX) has been proven effective in managing refractory generalized myasthenia gravis (MG), and its use is increasing worldwide. MG stabilization may initially require oral corticosteroid (CS) therapy, but its long-term side effects require the shortest duration of treatment. We studied the clinical effectiveness and usefulness of corticosteroids associated with RTX compared to RTX alone on MG remission. Methods: In a monocentric retrospective cohort in the Nice University Hospital, we compared naïve MG patients treated with RTX as first-line therapy alone (G1) or associated with CS (G2). After the RTX induction, we evaluated efficacy with the Osserman score (OS) and the requirement for any rescue therapy (IVIg or plasmapheresis). Results: Sixty-eight patients were treated with RTX, of which 19 (27.94%) benefited from an association with at least 0.5 mg/kg of corticosteroids. RTX-CS patients were more severe than RTX alone (OS for G1: 74.1 and G2: 64.94, p = 0.044). However, OS at 3 (83.44 and 83.12, p = 0.993), 6 (88.69 and 86.36, p = 0.545), 9 (82.91 and 85.73, p = 0.563), and 12 months (86.6 and 88.69, p = 0.761) from the treatment induction were similar. Rescue therapy following RTX induction was significantly higher for the RTX-CS (20.41% and 47.37%, p = 0.037). Regarding safety, adverse event rates were similar in the two groups (0% and 14.29%, p = 0.178). Conclusion: We suggest that RTX alone is as effective as RTX-CS in MG patients, indicating that avoiding steroids could reduce side effects, decrease rescue therapies, and not affect MG outcomes. [ABSTRACT FROM AUTHOR]

Background: Peripheral artery disease (PAD) in hemodialysis (HD) patients has a significant social impact due to its prevalence, poor response to standard therapy and dismal prognosis. Rheopheresis is indicated by guidelines for PAD treatment. Materials and Methods: Twenty‐five HD patients affected by PAD stage IV Lerichè‐Fontaine and ischemic ulcer 1C or 2C according to the University of Texas Wound Classification System (UTWCS), without amelioration after traditional medical therapy and/or revascularization, were selected and underwent 12 Rheopheresis sessions in 10 weeks. Improvements in pain symptoms using Numerical Rating Scale (NRS), healing ulcers and laboratory hemorheological parameters have been evaluated. Results: A clinically and statistically significant mean value reduction and of relative percentage differences between estimated marginal means (Δ), calculated at each visits, of NRS was observed, with a maximum value (−48.5%) between the first and last visit. At the end of the treatment period 14.3% of ulcers were completely healed, 46.4% downgraded, 53.6% were stable. Overall, no ulcers upgraded. A statistically significant reduction of the Δ, between the first and last visit, for fibrinogen (−16%) was also observed. Conclusion: Rheopheresis reduced overall painful symptoms; data suggest that it could heal or improve ulcers and hemorheological laboratory parameters in HD patients with PAD and ischemic ulcers resistant to standard therapies. [ABSTRACT FROM AUTHOR]

AbstractHaploidentical hematopoietic cell transplants (haplo-HCT) with donor-specific anti-HLA antibodies (DSAs) are associated with high rates of primary graft failure and poor overall survival (OS). Limited data exists regarding the effect of desensitization. Our institution began routine desensitization for patients with DSAs in 2014. Adult patients undergoing haplo-HCT at Washington University from 2009–2021 were identified and divided into three cohorts: no DSA, untreated DSA (2009–2014) or treated DSA (2014–2021). Desensitization therapy using plasmapheresis and IVIg was performed. Retrospectively, 304 patients were identified. 14 of 30 patients with DSAs underwent desensitization. By day +2, 57% of patients cleared all DSAs. After multivariable analysis, OS was similar between treated DSA and no DSA (HR: 0.69, p = 0.37). Untreated DSA had significantly lower OS compared to no DSA group (HR 1.80, p = 0.046). Desensitization with a backbone of plasmapheresis and IVIg before haplo-HCT may produce similar outcomes to patients without DSAs. [ABSTRACT FROM AUTHOR]

Background Case Presentation Conclusions Bickerstaff brainstem encephalitis (BBE) is an autoimmune disease affecting the brainstem, typically caused by a prior infection. However, BBE after coronavirus disease 2019 (COVID‐19) infection is rare. Here, we present a severe case of BBE after COVID‐19 infection, highlighted by increased levels of CXCL‐10.A 28‐year‐old woman presented with symptoms of cold and fever lasting 5 days, accompanied by numbness, weakness and unsteadiness in the distal parts of her limbs before being admitted. Upon admission, her condition was classified with a Glasgow Coma Scale score of E1V1M4, absence of bilateral ocular cephalic reflexes, eyes fixed in the midline position and pathological reflex in lower limbs. COVID‐19 antigen tests were positive, and cerebrospinal fluid CXCL‐10 levels were elevated. Positive serum anti‐GQ1b antibodies, along with other clinical findings, confirmed the diagnosis of BBE. Initial treatment with high‐dose intravenous immunoglobulin was ineffective, leading to mechanical ventilation on day 2 from admission. Additional steroid pulse therapy and plasmapheresis were initiated on day 7. Communication abilities were restored by day 19, and the patient was extubated on day 21. Continuous alleviation of symptoms was observed, with no sequelae at discharge on day 42.BBE related to COVID‐19 with high CXCL‐10 levels can become severe. However, early intensive immunotherapy, including plasmapheresis, might result in favorable prognosis. [ABSTRACT FROM AUTHOR]

Introduction: The experience of using therapeutic plasmapheresis in autoimmune and inflammatory diseases allowed us to propose and indicate this therapy in combination with Cuban biotechnological drugs in patients with COVID-19; a disease characterized by the uncontrolled release of cytokines that activate the proinflammatory response, acute respiratory failure syndrome, thrombotic events and multiorgan failure. Objective: To describe the results of the use of therapeutic plasmapheresis combined with Cuban biotechnological drugs in patients with worsening of COVID-19 disease. Methodology: The research was carried out during the second wave of the COVID-19 pandemic at the "Manuel Fajardo Rivero" Army Military Hospital in Villa Clara, during the months of March and April 2021. Case study involving 16 patients over 18 years of age with positive PCR-RT for SARS-CoV-2, with deterioration in their clinical and laboratory condition who underwent plasmapheresis treatment and Cuban biotechnological drugs: Itolizumab, Jusvinza, HeberFERON® e Intacglobin®. Results: 75% of the patients were classified as potentially serious. Half of the patients received Itolizumab and at least one therapeutic plasmapheresis session. The response was favorable, 100% had negative PCRRT, and D-dimer normalized more quickly, followed by C - reactive protein. Fewer plasmapheresis sessions were needed to achieve recovery. Conclusions: Therapeutic plasmapheresis in patients with COVID-19 was a complementary and promising treatment; combined with biopharmaceuticals, innovative and necessary to reduce the inflammatory and viral load and achieve the recovery of the patient with clinical worsening of his condition. [ABSTRACT FROM AUTHOR]

Potential kidney transplant patients with HLA-specific antibodies have reduced access to transplantation. Their harmful effects are mediated by the Fc portion of IgG, including activation of the complement system and Fc receptor-initiated cytotoxic processes by circulating leucocytes. Avoiding antibody incompatibility is the conventional approach, but for some patients this can mean extended waiting times, or even no chance of a transplant if there are no alternative, compatible donors. For these cases, pretransplant antibody removal may provide access to transplantation. Plasmapheresis is currently used to achieve this, with acceptable outcome results, but the process can take days to reduce the antibody levels to a safe level, so has limited use for deceased donors. There is now an alternative, in the form of an IgG-digesting enzyme, Imlifidase, which can be administered for in vivo IgG inactivation. Imlifidase cleaves human IgG, separating the antigen-binding part, F(ab')2 from Fc. Typically, within six hours of dosing, most, if not all, of the circulating IgG has been inactivated, allowing safe transplantation from a previously incompatible donor. For deceased donor transplantation, where minimizing cold ischaemia is critical, this six-hour delay before implantation should be manageable, with the compatibility testing processes adjusted to accommodate the treatment. This agent has been used successfully in phase 2 clinical trials, with good short to medium term outcomes. While a donation rate that matches demand may be one essential answer to providing universal access to kidney transplantation, this is currently unrealistic. IgG inactivation, using Imlifidase, is, however, a realistic and proven alternative. [ABSTRACT FROM AUTHOR]

Pregnancy‐associated atypical hemolytic uremic syndrome (P‐aHUS) is a rare disease. There are only few reports in the literature, and most are in the puerperium period. It is a thrombotic microangiopathy (TMA) characterized for microangiopathic hemolytic anemia, thrombocytopenia, and renal dysfunction. We report the case of a pregnant patient at 26.3 gestation weeks, who developed clinical features of TMA, neurological alterations, and septic shock; then after fetus and placental delivery, no clinical improvement was observed; a diagnostic protocol was performed due to suspicion of P‐aHUS, showing improvement after the plasma exchange sessions and eculizumab. We present here a brief review of the case since it is an entity that needs to be suspected during pregnancy when TMA features and requires an immediate diagnosis to provide timely treatment. [ABSTRACT FROM AUTHOR]

Background: Antibody‐mediated rejection (ABMR) poses a barrier to long‐term graft survival and is one of the most challenging events after kidney transplantation. Removing donor specific antibodies (DSA) through therapeutic plasma exchange (PLEX) is a cornerstone of antibody depletion but has inconsistent effects. Imlifidase is a treatment currently utilized for desensitization with near‐complete inactivation of DSA both in the intra‐ and extravascular space. Methods: This was a 6‐month, randomized, open‐label, multicenter, multinational trial conducted at 14 transplant centers. Thirty patients were randomized to either imlifidase or PLEX treatment. The primary endpoint was reduction in DSA level during the 5 days following the start of treatment. Results: Despite considerable heterogeneity in the trial population, DSA reduction as defined by the primary endpoint was 97% for imlifidase compared to 42% for PLEX. Additionally, imlifidase reduced DSA to noncomplement fixing levels, whereas PLEX failed to do so. After antibody rebound in the imlifidase arm (circa days 6–12), both arms had similar reductions in DSA. Five allograft losses occurred during the 6 months following the start of ABMR treatment—four within the imlifidase arm (18 patients treated) and one in the PLEX arm (10 patients treated). In terms of clinical efficacy, the Kaplan–Meier estimated graft survival was 78% for imlifidase and 89% for PLEX, with a slightly higher eGFR in the PLEX arm at the end of the trial. The observed adverse events in the trial were as expected, and there were no apparent differences between the arms. Conclusion: Imlifidase was safe and well‐tolerated in the ABMR population. Despite meeting the primary endpoint of maximum DSA reduction compared to PLEX, the trial was unsuccessful in demonstrating a clinical benefit of imlifidase in this heterogenous ABMR population. Trial Registration: EudraCT number: 2018‐000022‐66, 2020‐004777‐49; ClinicalTrials.gov identifier: NCT03897205, NCT04711850 [ABSTRACT FROM AUTHOR]

Objectives: Fluid creep, used as a drug diluent can contribute to fluid and electrolyte balance. Fluid creep brings substantial volume and electrolyte load to patients, especially in critically ill children. This study is conducted to evaluate the correlation of fluid creep with fluid and electrolyte balance in critically ill children. Materials and Methods: This cross-sectional study was conducted in a single tertiary center. We include children aged 1 month-18 years in the pediatric intensive care unit (PICU). Exclusion criteria were patients receiving renal replacement therapy and plasmapheresis. Fluids and electrolyte intake were recorded at admission and the first 24 hours in the PICU. Results: A total of 64 patients were observed. The sources of fluid intake are 61% from parenteral, 25% from enteral nutrition, and 12% from fluid creep. There were significant correlations between the volume (r = 0.304, P = .015) and electrolyte intake (r = 0.742, P = .035) of fluid creep with daily fluid balance. There is no correlation between fluid creep and electrolyte changes in 24 hours. Fifty-two patients used WFI (81.2%) as a drug diluent. Conclusion: Our study showed that fluid creep constitutes 12% of daily fluid intake. There is a correlation between the volume and electrolyte intake from fluid creep to daily fluid balance, so it is important to include the volume of fluid creep in calculating the fluid balance. Thus, it is recommended to use hypotonic fluid like WFI compared to NaCl 0.9% for drug diluent. [ABSTRACT FROM AUTHOR]

• Admission NCS helped in subtyping GBS in 85% patients. • AIDP was the dominant subtype and remained so till 3 months. • 47% patients had transition in subtypes, highest from equivocal and least from AIDP. • Axonal burden was reduced and conduction block improved following IVIg. • Neurophysiological changes however were not associated with 3 months outcome. Intravenous immunoglobulin (IVIg) and plasmapheresis (PLEX) are recommended in moderate to severe Guillain-Barré Syndrome (GBS), but there is paucity of studies evaluating its effect on nerve conduction studies (NCS). We report the effect of IVIg and PLEX on the NCS parameters and clinical outcomes compared to natural course (NC) of GBS patients. Moderate to severe GBS patients were included based on clinical, cerebrospinal fluid, and NCS finding. Six motor and sensory nerves were evaluated at admission, one month and 3 months, and NCS subtyping was done. Axonal and demyelination burden in motor nerves and early reversible conduction block (ERCB) were noted. Patients receiving IVIg, PLEX or on NC were noted. Outcome was defined at 3 months into complete, partial and poor using a 0–6 GBS Disability Scale (GBSDS). Seventy-two patients were included, whose median age was 36 years and 22(30.6 %) were females. 44 patients received IVIg, 9 PLEX and 19 were in NC, and they had comparable peak disability. AIDP was the dominant subtype at admission (58.3 %), which remained so at 3 months (50 %). The shift of subtypes was the highest from the equivocal group followed by AMAN and the least from AIDP. IVIg and PLEX group had more reduction in axonal burden and had ERCB compared to NC. 33(44 %) patients had complete recovery, and 40(55.5 %) patients had concordance in clinical and neurophysiological outcome. Transition of GBS subtype may occur at follow-up from all the subtypes, the highest from the equivocal and the lowest from the AIDP group. IVIg/PLEX treatment may help in reducing conduction block and axonal burden. [ABSTRACT FROM AUTHOR]

Current treatment guidelines of myeloma cast nephropathy (MCN) recommend the institution of plasma cell‐directed therapy and consideration of therapeutic plasma exchange (TPE), with the goal of rapid reduction of the serum free light chain (sFLC). However, the role of TPE continues to remain a subject of debate. The goal of this retrospective bi‐institutional study was to evaluate the clinical outcomes of TPE in combination with systemic therapy. Eighty patients were included in this analysis, of whom 72.5% had ≥50% drop in their initial involved sFLC. At 3 months from TPE initiation, the overall hematologic response rate (ORR) was 67.5% with a very good partial response or better (≥VGPR) rate of 40%. At 6 months, ORR was 57.5%, with ≥VGPR rate of 49%. The renal response rate at 3 and 6 months was 47.5% and 43.75%, respectively; the overall renal response rate was 48.75%. On multivariable analysis, every one unit increase in baseline creatinine (odds ratio [OR] 0.76, p = 0.006), and achievement of ≥VGPR (OR 21.7 p < 0.0001) were significantly associated with renal response. Also, a ≥50% drop in sFLC was favorably associated with renal response (OR 3.39, p = 0.09). With a median follow‐up of 36.4 months, the median overall survival (OS) was 11 months. On multivariable analysis, achievement of renal response (hazard ratio [HR] 0.3, p < 0.0001) and newly diagnosed disease (NDMM; HR 0.43, p = 0.0055) were associated with improved OS. Among NDMM patients, those treated with daratumumab‐based regimens had a trend for better OS (p = 0.15), compared to other regimens, but the difference was not significant. At the end of follow‐up, an estimated 40.4% of patients who were on dialysis were able to become dialysis independent. In conclusion, our study highlights the poor survival of patients with MCN. Achievement of early renal response is crucial for prolonged OS, with daratumumab‐based therapies showing promise. [ABSTRACT FROM AUTHOR]

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Background & Aim: Hypotension is a common complication associated with plasmapheresis. Elevating the legs and using elastic stockings are nursing interventions aimed at preventing hypotension. The objective of this study was to compare the effects of elastic stockings and leg elevation on the prevention of hypotension during plasmapheresis. Methods & Materials: This randomized crossover clinical trial was conducted on 35 patients undergoing plasmapheresis at Beheshti Hospital in Hamadan from 2020 to 2021. Patients were selected based on convenience sampling and then allocated to four different methods in four sessions using random permuted block designs: elastic stockings (A), leg elevation (B), a combination of elastic stockings and leg elevation (C), and a control group (D). Blood pressure was monitored before, during (every half hour), and half an hour after the completion of plasmapheresis. Data analysis was performed using SPSS version 24, applying repeated measures ANOVA with a significance level of 0.05. Results: During plasmapheresis, systolic blood pressure decreased over time in all four methods (P<0.001). Blood pressure measurements in intervention methods A, B, and C were higher than in the control group (P<0.001). Among the intervention methods, blood pressure in method C was higher than in methods A and B, while method B was higher than method A (P<0.001). Conclusion: The use of elastic stockings in combination with leg elevation is more effective in preventing hypotension. Therefore, it is recommended as an easy and cost-effective method for preventing hypotension in patients undergoing plasmapheresis and for nursing staff to implement. [ABSTRACT FROM AUTHOR]

Background: Isaacs' syndrome, also known as neuromyotonia or peripheral nerve hyperexcitability, is a rare disorder that affects the peripheral nervous system. Clinical findings include cramps, fasciculations, and myokymia; however, there are few reports of dental treatment for trismus. Case presentation: A patient with trismus due to Isaacs' syndrome experienced swelling and pain in the gingiva surrounding his right lower first molar. He was diagnosed with chronic apical periodontitis by a dentist near his home. However, the patient was informed that dental treatment and medication could not be administered because of the presence of Isaacs' syndrome, and he visited the Geriatric Dentistry and Perioperative Oral Care Center at Kyushu University Hospital 2 weeks later. The patient's painless mouth-opening distance (between incisors) was 20 mm at that time, and medication, including amoxicillin capsules and acetaminophen, was administered because the dental extraction forceps or endodontic instruments were difficult to insert into the oral cavity for treatment. Two months after his initial visit, the patient visited us complaining of pain in the same area. However, he had recently undergone plasmapheresis treatment in neurology to alleviate limited mouth opening and systemic myalgia, resulting in a pain-free mouth-opening distance of approximately 35 mm. During this temporary period in which he had no restriction in mouth opening, we performed tooth extraction and bridge restoration on the mandibular right first molar and created an oral appliance for sleep bruxism. Conclusions: Plasmapheresis therapy transiently reduced trismus, rendering dental interventions feasible, albeit temporarily. This case report underscores the importance of close collaboration between neurologists and dentists who encounter similar cases while furnishing valuable insights to inform dental treatment planning. [ABSTRACT FROM AUTHOR]

Background: Appropriate treatment reduces the severity and duration of relapses in demyelinating diseases of Central Nervous System (CNS). If high-dose corticosteroids treatment fails, therapeutic plasma exchange (TPE) is considered as a rescue treatment. Objectives: This study aimed to investigate early clinical response and complications of TPE and prognostic factors in CNS demyelinating relapses. Design: This prospective observational study was designed in a tertiary center during one year. Methods: All adult patients diagnosed corticosteroid-resistant Multiple Sclerosis (MS), NeuroMyelitis Optica Spectrum Disorder (NMOSD), idiotypic Transverse Myelitis or Clinical Isolated Syndrome relapses, were eligible. Clinical response is defined based on Expanded Disability Status Scale (EDSS) at discharge. Clinical and laboratory complications recorded. Results: Seventy-two patients were analyzed which 58.3% patients were female. MS was diagnosed for 61.1% of cases. Thirty-five patients (48.6%) responded and the mean differences of EDSS significantly decreased 0.60 score (CI95%:0.44-.77). Electrolyte imbalances and thrombocytopenia occurred in 80.6% and 55.6% of cases respectively and 40.3% of patients had systemic reactions. However, 26.4% patients experienced moderate to severe complications. In patients with moderate to severe disability, responders were younger (MD: 8.42 years, CI95%: 1.67-15.17) and had lower EDSS score at admission (median:6, IQR: 5.5-6 against 7.5 IQR: 6.5-8). The risk of failure was higher in active progressive MS patients compared with RRMS patients (OR: 6.06, CI 95%:1.37-26.76). Patients with thrombocytopenia were hospitalized more than others (MD: 1.5 days, CI 95%: 0-3). Females were more prone to hypokalemia and systemic reactions (OR: 3.11, CI 95%:1.17-8.24 and OR: 6.67, CI 95%:2.14-20.81 respectively). Conclusion: The most common indication of TPE was corticosteroid-resistant severe MS relapses. About half of the patients presented an early clinical response. Lower disability, younger age and RRMS diagnosis are prognostic factors of better response. One out of four patients experienced moderate to severe complications, mainly electrolyte imbalances and systemic reactions. Appropriate interventions against these complications should be considered during TPE, especially in females. [ABSTRACT FROM AUTHOR]

We report a case of severe hypertriglyceridemia (HTG) complicated by hyperviscosity syndrome as a possible adverse reaction to risankizumab-rzaa in a 49-year-old male with a history of longstanding uncontrolled type 2 diabetes, obesity, and coronary artery disease with prior ST-elevation myocardial infarction. On admission, the patient presented with xanthomatous plaques, chest and epigastric discomfort, and headache. Subsequent blood testing revealed severely elevated triglyceride (TG) levels at 7670 mg/dL (86.59 mmol/L) [reference range: <150 mg/dL; 1.69 mmol/L] and total cholesterol at 934 mg/dL (24.14 mmol/L) [reference range: <200 mg/dL; 5.17 mmol/L]. Triglyceride levels decreased and symptoms resolved with dietary restrictions and plasmapheresis. At follow-up, his TG remained elevated but improved, and he was advised to continue lipid-lowering medications as well as cessation of risankizumab. While the patient presented with high risk factors, we posit that the subacute presentation of severe HTG is a possible result of his recent course of risankizumab-rzaa therapy for management of psoriasis. This is noteworthy as pharmaceutical surveys and clinical trials do not list severe HTG as an adverse effect. Postmarketing surveillance studies are essential to confirm this potential association and monitor drug safety. In summary, this case highlights a possible link between risankizumab and severe HTG, emphasizing the importance of ongoing pharmacovigilance to identify and manage unexpected adverse effects associated with new medications. [ABSTRACT FROM AUTHOR]

Introduction: Lactate is a useful prognostic marker, as its level increases in hypoxic tissue and/or during accelerated aerobic glycolysis due to excessive beta-adrenergic stimulation and decreased lactate clearance. The Surviving Sepsis Campaign Bundle 2018 Update suggests premeasurement of lactate within 2–4 h so that physicians perform, assist, administer, and introduce lactate-guided resuscitation to reduce mortality due to sepsis. Methods: A total of 108 patients with septic shock who underwent continuous renal replacement therapy (CRRT) for acute kidney injury were enrolled in this observational study. Demographic, clinical, and laboratory data were collected, and patients were divided into two groups: survivors and non-survivors. Results: Multivariate analysis demonstrated that lactate levels at 24 h after initiation of CRRT treatment, but not lactate levels at intensive care unit (ICU) admission, were associated with mortality. Lactate clearance was associated with lower mortality among the survivors (OR = 0.140) at 6 h after ICU admission and late mortality (OR = 0.260) after 24 h. The area under the ROC curves for mortality was 0.682 for initial lactate; 0.797 for lactate at 24 h; and 0.816 for lactate clearance at 24 h. Conclusions: Our result reinforces that the determination of lactate dynamics represents a good predictor for mortality, and serial lactate measurements may be more useful prognostic markers than initial lactate in patients with septic shock. [ABSTRACT FROM AUTHOR]

Our limited understanding of complex neurodegenerative disorders has held us back on the development of efficient therapies. While several approaches are currently being considered, it is still unclear what will be most successful. Among the latest and more novel ideas, the concept of blood or plasma transfusion from young healthy donors to diseased patients is gaining momentum and attracting attention beyond the scientific arena. While young or healthy blood is enriched with protective and restorative components, blood from older subjects may accumulate neurotoxic agents or be impoverished of beneficial factors. In this commentary, we present an overview of the compelling evidence collected in various animal models of brain diseases (e.g., Alzheimer, Parkinson, Huntington) to the actual clinical trials that have been conducted to test the validity of blood-related treatments in neurodegenerative diseases and argue in favor of such approach. [ABSTRACT FROM AUTHOR]

Introduction: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening acute mucocutaneous disorders usually triggered by drugs. In this study, we aimed to evaluate the factors affecting mortality in patients with SJS-TEN. Methods: Our study is a retrospective cohort study, analyzing data collected from a total of 12 tertiary care centers between April 2012 and April 2022. Results: The study included 59 males and 107 females, a total of 166 patients, with an average age of 50.91 ± 21.25 years. Disease classification was TEN in 50% of cases, SJS in 33.1%, and SJS-TEN overlap in 16.9%. The average SCORTEN within the first 24 h was 2.44 ± 1.42. Supportive care was provided to 99.4% of patients. The most commonly used systemic immunomodulatory treatments were systemic steroids (84.3%), IVIG (intravenous immunoglobulin) (49.3%), and cyclosporine (38.6%). Plasmapheresis was administered to five patients. While 66.3% of patients were discharged, 24.1% resulted in exitus. Our comparative analysis of survivors and deceased patients found no effect of systemic steroids, IVIG, and cyclosporine treatments on mortality. Univariate analysis revealed that the SCORTEN scores on days 1 and 3 as well as the rates of detachment at the onset and during follow-up were significantly higher in deceased patients compared to survivors. The rates of fever, positive blood cultures, and systemic antibiotic use were higher in deceased patients compared to survivors. The presence of comorbidities, diabetes, and malignancy were significantly more common in deceased patients. Multivariate regression analysis indicated that over SCORTEN 2, the mortality risk exponentially rose with each SCORTEN increment, culminating in an 84-fold increase in mortality at SCORTEN 5–6 (odds ratio [95% confidence interval]: 13.902–507.537, p < 0.001) compared to SCORTEN 0–1. Additionally, the utilization of plasmapheresis was associated with a 22-fold increase in mortality (odds ratio [95% confidence interval]: 1.96–247.2, p = 0.012). Conclusion: Our study found that a high SCORTEN score within the first 24 h and the use of plasmapheresis were related to increased mortality, while systemic steroids, IVIG, and cyclosporine treatments had no impact on mortality. We believe that data gathered from one of the most comprehensive studies which we conducted on SJS-TEN will enrich the literature, although additional research is warranted. [ABSTRACT FROM AUTHOR]

Introduction: Hyperviscosity syndrome (HVS) is a significant complication in Waldenström's macroglobulinemia (WM), although the significance of plasmapheresis in clinical practice has not been clarified. To confirm the efficacy and safety of plasmapheresis followed by primary therapy for WM with HVS, we retrospectively conducted this study. Methods: Untreated WM with HVS, or serum immunoglobulin M (IgM) levels ≥4000 mg/dL, were analyzed. The basic therapeutic flow was conducted as follows: (1) performing plasmapheresis, (2) followed by primary therapy without rituximab, and (3) performing the second cycle. The serum IgM reduction rate and adverse events (AEs) were evaluated. Results: Ten patients were enrolled. The median serum IgM levels at diagnosis, post‐plasmapheresis, after the first cycle of primary therapy, and after the second cycle were 5174, 2900, 3286, and 2657 mg/dL, respectively. No patients experienced IgM flare or bleeding AEs. Conclusion: The therapeutic flow offers sufficient efficacy and safety in WM with HVS. [ABSTRACT FROM AUTHOR]

Background: Therapeutic plasma exchange (TPE) is utilised in the management of a limited number of paediatric renal conditions. Despite its widespread acceptance and advancements in the practice of apheresis, there remains a paucity of data pertaining to paediatrics. We present a large retrospective review of our cohort of paediatric patients undergoing TPE for renal indications, outlining their outcomes and complications. Methods: A retrospective chart review was conducted for all patients (under 16 years) undergoing TPE for renal conditions between January 2002 and June 2019 in Ireland. Demographic and clinical data were extracted, with patients anonymised and stratified according to their pathology. Results: A total of 58 patients were identified. A total of 1137 exchanges were performed using heparin sodium anticoagulation. The median age was 35.5 months (IQR 18–110 months). The leading indication was neurological involvement in Shiga toxin–producing Escherichia coli haemolytic uraemic syndrome (STEC-HUS) (n = 29). Complications (minor or major) occurred in 65.5% (n = 38) of patients, with most experiencing minor complications 58.6% (n = 34). Asymptomatic hypocalcaemia was the most common complication in 43.1% (n = 25). Conclusions: Our experience of TPE, spanning 1137 exchanges, proved a safe, well-tolerated therapy. Most complications were minor, and with therapy conducted in specialised centres, there are very low levels of adverse events. [ABSTRACT FROM AUTHOR]

Background: The impact of chronic therapeutic plasmapheresis on humoral response following COVID‐19 vaccination is poorly documented, especially among patients treated with double filtration plasmapheresis (DFPP). Objective s : This retrospective single‐center study evaluated the humoral response after SARS‐CoV‐2 vaccination and studied anti‐SPIKE seropositivity and antibody dynamics in patients with chronic DFPP at our institution. Method: All patients undergoing chronic DFPP at a tertiary center in France from December 2020 to November 2022 were included. We defined one patient subgroup as Group 1 to evaluate anti‐SPIKE seropositivity after vaccination, with three groups based on their anti‐SPIKE titers: (Group 1A) nonresponders (<0.8 UI/mL), (Group 1B) weak responders (0.8 to <250 binding antibody unit [BAU]/mL), and (Group 1C) strong responders (>250 BAU/mL). Group 2 served to evaluate antibody dynamics with anti‐SPIKE levels measured 3 months after initial vaccination, Group 2A having a sustained level and Group 2B a declining pattern. Results: The 21 patients included had a median age of 63 years, and 13 (56%) were male. The indications for chronic DFPP mainly included dysimmune pathologies (15; 71%) and familial dyslipidemia (6; 29%). For the humoral response to vaccination in Patient Group 1, the only nonresponder was a patient who had undergone kidney transplantation 30 months earlier and was on immunosuppressive medication. For Patient Group 2, the median follow‐up of antibody titers was 13 months [12–13]. Two distinct patterns of anti‐SPIKE dynamics were observed: a rapid decline in anti‐SPIKE antibody titers within 6 months following the initial vaccination or booster dose (n = 10 [71.4%] Group 2A) and stable anti‐SPIKE levels above 250 BAU/mL over >6 months (n = 4 [28.6%] Group 2B) with more patients with familial dyslipidemia in the former. Conclusions: Humoral response to SARS‐CoV‐2 vaccination appears robust in patients undergoing chronic DFPP and may be linked to patients' immune status rather than DFPTP itself. Our results support current recommendations for administering three doses of vaccine with a booster every 6 months. [ABSTRACT FROM AUTHOR]

Membranous nephropathy is the most common cause of nephrotic syndrome (NS) in non‐diabetic adults; in 80% of patients it is idiopathic (PMN). PMN has an autoimmune pathogenesis, 70%‐85% of patients have increased titer of antibodies to the podocyte membrane antigen PLA2R. The etiological, prognostic and predictive role of the Ab anti‐PLA2R is demonstrated. Standard therapy consists in anti‐CD20 monoclonal antibody rituximab (RTX) combined with steroids or immunosuppressants according to the risk of progressive loss of kidney function. The immunosuppressive therapies are potentially associated to severe adverse events that lead to protocol suspension. Given their pivotal pathogenetic role, serum clearance of anti‐PLA2R with plasmapheresis could have a beneficial impact on NS, particularly in patients not requiring or tolerating standard therapies. In this series, we present three cases of PMN anti‐PLA2R related treated with a RTX plus plasmapheresis approach and demonstrate its overall effective role on anti‐PLA2R titer and clinical outcomes. [ABSTRACT FROM AUTHOR]

Bullous pemphigoid is the most common autoimmune blistering disease induced by autoantibodies against basement membrane anchoring proteins (anti‐BP‐180 and anti‐BP‐230). The disease generally appears after the age of 70 and is associated with a 23.5% 1‐year mortality, especially in diabetics, or in the presence of ischemic heart disease and high anti‐BP‐180. Treatment starts with topical steroids but some patients may require oral steroids and systemic immunosuppression. We, hereby, discuss a diabetic patient on chronic hemodialysis, with severely relapsed bullous pemphigoid under biotherapy with omalizumab, who was successfully treated with five sessions of double filtration plasmapheresis, thus avoiding the need for systemic steroids. [ABSTRACT FROM AUTHOR]