Plasmapheresis

  • 3,191 views
Uploaded on

 

More in: Education
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads

Views

Total Views
3,191
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
63
Comments
0
Likes
1

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. Plasmapheresis Principles, Methods & clinical use
  • 2. "$ # """ ! "4567 3 0 1 ,2 & , ,-* ./ + )* % & '(% "1 : 3 ;469 + 8 & '(% 978 ?964 ? 2740 ?18?5 <= > D @ 2 ) A BC E = 2/ A> F C 3 . E > 0 1 ,2 . E > "RM 475 G6 4567 # / = I4J 5H = 4LI54HH K E (= 2/ > ! ! 2 C K 2/ ? 2/ ? M # ): 2/ = K / 2 2/ ? . . P ) 2/ ? N)D E O 2/ M # ): 2/ R + & Q = 0 1 ,2 & , ,-* ./ R + = 3 + & %2 > 67 . 31 G S A= E(@ 6JT ! > + * %2 # + E@ V -U G S 3 ! 2 H76 ?HI9 ?L79T?47 ?6 <= > * LJTT A W [ = : A + )> ! .= X PY Z > ! .= ? )* % www.ibto. ir 0 1 ,2
  • 3. ! ! <>. M # ): 2/ 0 1 ,2 K % <>. 2/ ? 2 0 1 ,2 + #% ] K 2/ 2 C K 2/ ? 2 0 1 ,2 ^ _'(* ` N)D E O 2/ R>. ] K #% K &a + Y ^ * _'(2 .. P ) 2/ ? 2 0 1 ,2 <>. = K / 2 2/ ? 2 0 1 ,2 M # ): 2/ R + & Q =
  • 4. E= b ,* " >= / c d E/ 0 2@ ! / + *
  • 5. )*(&'%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% !" #" $ &*(45%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%-". /0 123 +, ! $ "# ( % &' % &' , + )* 8* .3 4 5) - 6 , '7 2 - . /01 8A 9 9 & ' : ;) < = A : 3 @ - < > : ;) ? 3 - . /01 $ B C % D E 1 : F) G < 4 (58%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%1" 67 -". /0 + G$ H F) A B C < >I A > 6 , ' B C , JK 1 < B C < > - 9 A 8FFP 2 B " *, ) < B C AG 8Source pelasma 2 LM" < B C * %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% /0 9 67 : 5)()8&%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%1< , -". /0 + ; N H F) N %7 I K 5D % ) *
  • 6. N O# - 9 "-P ( > : - &Q B I K 5D R F) < B C E 1 G TPE JK ' A TPE I F' F) N :S TIF !( < F U* ! > ,7 - ! , J" TPE JV ='%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% BC 9 CTPE 1>< ? @ A ! 6 &9 !G < F IWC D =5%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% TPE : ! I P"9 !$ X 9C ' 7 YZ 9C ' 7 Y Z 37 < > P"9 $ % [)?> $ ^ ]<> )9, # ] $ 6 ") $G B3 9 ? > $G FFP_ ) <>< B -4 $G 3) )8'()='%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% TPE9 7 B F"6< DE 0 )8L%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%G"H < @I/JK ($ 1 -= 3 < ,: & ) & : S -= 3 < ,: & ) & 6 Q " G % IMW " " A Z C ; M5] < > " N <S9 M5] * 1< ,: & < B- =
  • 7. ! 4 &9 ) Q `V ) $ <S9 M5] E [ U < > < - 7 - Z C ; a IWC D ( 99 < = ] - _M) 4 b "B D M5] IWC D = *9 )&'%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%1< M 1< K @I/JK Z" M )Z) M ) " Z Z 3 B> ! 4 &9 < > :; ) $ , c[ ? > " ( ) 3Q 9 ( & &9 % D 4 d^ F < F 9 ' < > * ""9 = G D < > 4 & &] - < - 7 N Z" M )% B % B ) Z 3 B> D E9 ! RBC e3 D <,C 7 Z C 7 B 7 )4)%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%G"H < " @I/JK G B" 3 - &Q 9 G f Q " GA * P gF <= 3 &Q GN &5 E[ ) G ZB[ O3c G! ) < R] G$ Reject A( < B- ] )*)%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%GBN3 GB C J @I/JK A B3 [&9 ? > A [' < B - AA O B[ > 1 , P - ,h A M9 1 L
  • 8. ! " # $" % & ' " ( " # $" ( )& ( *+ " , - - *+ . / " + ) + 0 1+ 9 :& $ . +$ ;< " # + =, 2 /+ 3 ( $ . 2( - 4+$,# 3 5 ,( 6 7. "8 *# @> 3 ? %- ( > /& $- A3B5! 30 $ 0", >30 ( 6 ,C ! 3<- E 6 * + %F -. ( - 4+$,# 3 5 . 0 A) A -$ D D+ # >/) =5& 6 " , 4+$, # 3 5 =" ( 6 26 30 . ,( G),- '+ A! ( & - A3 $ @ ( H- AA6 - H 3( - =" *+ $ 6 I JK( + <& 0 4+$,# 3 5 M: - I JK( ! A+ # " 9L :& ( ) & ( " - @; ( ,N *+ <- O P " ,Q !" #! $ %!
  • 9. &
  • 10. !% ! + !( , -. * () 9$ - ( " > "8 R- ( >+, ( . ,( #,S . 0 " !E , " 3 5 >%A U % & . + ) . 0T# 7*+ . 0. "8*# $ ., ,/( ( 8 @> /+ 3 ( - ( 9 !5 " 9 :& $ 3 Q! V - 6 ( .0 $ + 4+$,# 3 5 @> 3 ? %- +A 87 (, . /F < 9 :& , ,( 6 E 6 *+ W FX& $ ? 0 ./ " "[ 7 U ( 6 ,- YZ 30 " , 7 7* JJK - @ ( - 4+$,# 3 5 A F ( . 0 ,( 6 " < W K- ( $- A- B5! 30 $ %3) & 6 ,C ! 3<- > /+ ( + ! 0"^ D " 30 . 0 3A0 " 9 /A ]F 7 ( 3 $ F -8 ,+,:& @ + 3 - + '36 . %( . 0O P ,N *+ > H 6 & " /( " . 3 , S /) , 6 . B8 E A) A3) 3 ! . 09 ! 2- " 0 _ 3A0 $ 3& B " , & 3 3U $- Y6 ,+ - > , T ,RU ! , 6 . B8 E A) >+ 3 @; _ 3 - . + - E 6 *+ /& 6 . 3U 5 F ; 6, " +, 3:- . B8 E A) $ * A130 @;+ S ` 3 /% 0( / '
  • 11. %$#" ! aphairesis - , ! . * /- 01 * ' ( ) *+ , ! &' % ! ! &23 ! 51 &' 4 # 7 01 * 8 9 4 :;< ! * 9 - 6 + * 01 * 2 –# @ - 3 '8 A9, 7 2 6 % 2, * ! =9 > + ? E B %1 G 2 A F 9 29D ' CD 2 1 ! & CD ) F I1 J ! F & CD + * 01 * H & CD – @ K L2 D M9 > N O ! & CD ( L F D 2P ( L F D . * - !> 2, G R & CD Q F I1 J ! ! ! ' & CD &23 ! , ! ! 1 &2! ! 1-F ! *U1 2SF 1 T ! & CD - &F ! > 2P ! K L F D ) ? < & CD 01 * W ' ! * 8 X Y Z D V2 ? + -Y I 6 !7 F8 & CD ; &R< ! 1 [R< A % G R +2 A $ 2 ; 2 9 " & CD A; Hendon ! F 1 1 ^1( ? ! &' 1 1 2X]F + F ! ! RF R 1-F ; 7 * + * 01 * ! I 2< 1 1 )&? + 7#_`@ 8 1 + 2! 2 + 1 %$@" ! 1 6! ; 1 1 1 ! 1 ^ 1 + #_`_ 8 1 Fleig % 1 1 & CD 01 * ^ 1 #_#E 8 1 ) 3 a 1 6&' Abel ! 1 2&' 2! X :; ! b2c F 7 ! ! S 29 SY 2 &; 1 7S *+ 11 ' ! 2, 9 ?1 ! -2 & ': D FG 1 T !G %$B" & 2!a2D 1 F4 2! = 1 GR 1 & CD 1 - Cytapheresis 2- Leukopheresis 3 - Erythrocytapheresis 4 - Plateletpheresis 5 - Plasmapheresis
  • 12. '+2dF D R 2 F ? I1 3 a & ! R ; 1 2 & CD 2SF 7 2 ^1 h, , g* ! f A; 1 ? ! :9O e 1 2AO &< D 2, 3 2 '^ 1 + +62 7 * iD 6 1 1 * ' 1 = +2 j&' ! R 1-F L = 8A ! * 0 * 2 h7 ! R 1 :F S ! , 9& FC6 7 S 1 + 1 2Y * ' 2 % ! L= 62 CD * ' ;2 a 2D ! -&' 7#_H` ' ) #_E` ' * 1 8 1 %$B" F ;, = 7 1 ^ 1 ( ? ! &' 7 F 2D 1 8 j> % = & CD ^ 1 * ' 1 2SF ! Carifols – Lucas 7#_H@ & CD L = = ! - 3 8 A9, K 7 , ' ) * :2F F + ! = +2 j&' % ,! ' ! 2Y * D =' ( - 3 '8 A9, ^1 ! G R % ^1 -, 1 Z ! * 1 ! C A 1 &2! h 1 1 1 1 +2 j&' % ! 1 2;! O ! I 2 F * ' 1 '[R< 2SF ! 1-F ' ! Y - 3 8 A9, 7 kF 1 g! +6& ^1 % 1 * ' Y * ! X ) ; + % l ! R < Cohn L = G # )6 )A3 8 e` a2! G !L = = Edwin Cohn #_H` ' 1 * ' 1 2SF ! 1 ! 4 * A n J1 W k ! De Laval m F 7 ! ) AF 1 ^1( ! G S p O 1 & CD >! o AS! 1 ;! [ ;2 ( 1 * - On – Line 6 ' Y + %$@" 1 i, D 8 A Latham G 4 ! ! + % ! ) 7 ! IZ k] R2 1 [' +2? 1 2 >! AS! 1 1 n& ! Cohn ! L = G <O % 1 < O+ ' A q !8<
  • 13. +2! 1 RF S2 +2 S 6 7 George Judson 7#_e@ 8 1 r 1 Emil.J.Freireich ! $ NCI " ; 99& +2! 2 ; 1 $eIBM" 99& %$H" ! + - 2 92 & ! C A f 2* ! ^ ;D 1 ! (& ! '1 R ; s 2 Y ( !$ NIH" S! 9 2 ; 1 Judson 3 ! + GR ! 1 3 2 < O 6 6 + ! GF * ' 2 6 ! 'Y 2SF ! NCI IBM &< ! Judson t$B" 1 62 CD ' ? &R ) Y + % IBM @__` Y 2 F ! * D +2 ! 1 G ! ;! [ ;2 ( ! ) fCA3 W k 1 A6 $E"Latham G u@ )6 Y + % 1 [' 1 * [R< ^ D 6 69&? +2 h ! ! 'Y % ! - 3 '8 A9, 2 = 7 2 , 7 CD 1 n& 7 & CD Q F G R ! 1 3 D & -2&F G- * 2 1 L= G 9? ! = 1 3 = 1 ! ' Y 2 F ! D ? ! 7 ] 7 = 1! ' %$H" , $E" NCI/IBM @__` Y uB )6 6 - International Business Machines 7 - National Cancer Institute 8 - National Institutes of Health
  • 14. M ! '1 ,1-! ! G +2&' ! 2 * ! Aminco * ] ! 1 * Aminco 1 F 2 ) * L= % ! &? 1 7 ! 9* 1 ! k ? + F( - 7 & CD 2; T * k ? + F(A Z ! J ? + F( - 7 ;' 1 1 2; + F(A 9 J ? +2! 1 ' CD 62 < * k ? + F+2Y " - 3 '8 A9, &' * ' 2 , ' 2 = K % ! & CD % 7 1 * Z )! X n3 1 , 1 3 $ 2; T 1 n& 7 v 1 3 J * * ' Z1 29>F '8 m F 7 * J ? 4 ' ! !G O ! * ' &;3 w=< 2 1 k ? % % ! C F R = )! 3 7Aminco % ,! ! 8J T Y + %$B" , 1 3 x 1 #_rr 8 1 IBM @__r Y 2A W k 1 A6 62 CD 8 ( !L= G 1 ! Aminco Y 7L = G ! ; X 1 ! ! & R< ( 78 + % ! + -Y I ! % F 7 )J < 9 F[2>c ' Z R2 1 a' 1 , 9* bg 1 y g* 8 +2! * h ':;h ! ' Y + [S [' 1 [ ;2 ! ' 1 * 6 1 ! * I1 J1 ':;h + % ! 0 * 7 * Cobe K& ! IBM a>! % ! [' &23 , 8 < +2? 1 * ! R 7 ':;h )q n 1 S ! '^CF % & 2SF 1 @__r L 6F L 6F G F , :;h ! L= +2 ? ! #_r_ 8 1 CS B``` %$H" 2 R #_ss 8 1 Cobe Spectra Y ! :;h !L = $E" IBM2997 Y uE )6
  • 15. x 1 F1 RF I1 k! #_s` ' ) 1 7 2 F Fenwall 92 ! CS3000 z )6 ! * h T=] ) G ! Y ( 7 92 + % ,1 3 %$e" ! F K % X c <) * CD P & CD 7 T=] ( 1 )6 ! T=] ( 1 ! G-2 6 = ! 7' 2 , % & 1 n& 1 ' CD , I1 k! 7 ' 2 , CD ^ 1 = ! F 1 & CD % 7I = % & 1 n& & SPECTRA ? ]F 92 ( ^ !4 Cobe K& #_ss 8 1 ! -SR (2F F 4 + 1 1 Cobe/IBM @__r I 2J k* 1 2;! Y + + ! C? % & 2 F 7 2= 8 A9, , )3 < ! 1 CD IZ k] F 2K ' % ! 1 &2! N F ! 8 X )! 3 1 '^ 1 G R ! ! { ] Spectra 1 2 G ! '+2 Cobe Spectra , Fenwall CS - B``` Yv 7 g2] * > - $Stem Cells" 2 ! '8 9 1 n& ! ;' 1 %$e" 2, 1 3 = 1 2SF Latham x !| ! 9 ( Haemonetics K& O* !% ,1 3 M ! A; < ! '1 1 7 + % & 01 * M & ! RBC 7 1 F 2 ) * Y'7 )6 Y 01 * ! F(A 9 J ? & CD )' RBC [ }? ! 1 7I = ' ;2 1 :2F F ! 1 * J ? 7 F :2F F + ! % , { O 1 R! * J ? 2X! & D 1 RBC Y ' % & 1 n& 1 SY 2 1 / - % P 1 ! )&? + 29>F RBC K % M3 ! % 2 Pass ( ! ' % , ! ' ! * /- (2 D 2 A F , 2, : 1 S 2 , CD 1 n& % 2 1 Pass ' F a (2 D 2 , ? 7 JC* I1 k! ! CD 2 F ! n ! )6F D ( 1 & CD ^ 1 + 1 % ' a - @`` mL/min ! s` mL/min < 1 - 3 2= 8 A9, 3 A; 1 g! CD 1 n& = ^1 ! 8O _ 2! 1 2;! 7 Y + = 1 ! 01 * [R< % ;2 1 ! 9 - Extracorporeal
  • 16. (F (2 6F ( F %$@`` mL <" G ^1 $H`` mL <" S ' 1 ! 1 &2! , ' 1 1| '(2 6F = R! F < 1 7| ! Y 7 ! C? % & )6 %$r" F(A 1 2;! G ! '+2 + h * ! R f S 71 i m F 1 i, D V2 8 J 1 ! ' 2D F ;, !1 , 2 ! ' !1 S * (2F F &2 Y 4 ) ^ ;, ! y 1+ G F% 8A ! 1 ^1( ? ! 1 & CD & F !> h ' 1 * - ! F ! '1 - G 2 1 k % , ! 1 &2! ' !1 * U ' )26 F
  • 17. !" # 1. Pineda AA. Applications of Therapeutic Apheresis. Myoclinic proc. 1994, 69: 893. 2. Winters JL, Pineda AA. Hemapheresis. In Henry JB(ed): Clinical Diagnosis & Management by laboratory Methods. 20th ed. WB Saunders, 2001:776-805. 3. Kambic HE, Nose Y. Spin Doctors: New innovations for centrifugal apheresis. Ther Apheresis. 1997, 1: 284. 4. Corbin F, Cullis HM, Freireich EJ, et al. Development of apheresis instrumentation. In McLeod BC, Price TH, Weinstein R, eds. Apheresis: Principles & practice. 2nd ed.Bethesda, MD: AABB press, 2003:1-27. 5. Corbin F Cullis HM, Freireich EJ, et al. Development of apheresis instrumentation. In McLeod BC, Price TH, Weinstein R, eds. Apheresis: Principles & practice. Bethesda, MD: AABB press, 1997:1-26. 6. Gilcher RO. Apheresis: Principles and technology of hemapheresis. In Simon TL, Dzick WH, Snyder EL, et al(eds). Rossi's Principles of Transfusion Medicine. 3rd ed.Lippincott Wiliams & Wilkins, 2002:649-657. 7. Simon TL. The collection of platelets by apheresis. Transfus Med Rev. 1994, 8: 132-145.
  • 18. ! ! "# $ % ! ** , - !. % - / On–line & '( ) *+ 9Set5 ' ,:; % 9 7 8 '% , %6 , 50. 23 4 10 0 0 BCA @A ? - 0 - 0 , > =< + $ 0+ "# ' -) ) ? ** ', > 0I H J * 9B5 ** 0 D 0E F '? % G H -2 . M 1 ** , 78 L ? %' / ' %8K! , > 6 0 M = , % , - 0> N > J OP : %? 0 ! "# Q 3 U9T5 ** 0 R% *S - ! "# ' , > 0 9W) ( VB U *0 YN + % - 0* X 9O B O% * * T Z% ** [ VT [ %( Z V@ @ 0 P O^ 8V] !$ % & #" !$ % & .? ? 1 '% L :F ( > 0 .% 23 4 -P 8Z - F 6 - X0 9- N 5 M <P % NI 8 % '? 10 a? 6 & % _ S F - : N -` 6 % a? 6 Y % 6 6 >* 6 6 - N _? - 0E % I - N - 0 ? 10 . - ` 6 & ? ! "# U: b6 - 6 c 6 ! '? - N X0 K. % - ` % 1 Intermittent Flow Centrifugation (IFC) 2 Continuous Flow Centrifugation (CFC) 3 Affinity Adsorption Aphesis
  • 19. -+ 6 9@ ]5? . ' ,d [1 % : e : ) + ,: ) 1 ,: *) : "# '% W[ P ' ,- ` % D $F f" 0! ( - % # 0H - H - 9 ,: ) 1 - ` ? . ' ,d [1 % % d g *h - 5 Y, % D ' ,- ` X )8 % , 0 : ^# O * ! & ' 4 ' F 0[b -N % ' - 10 M <P ' ,-N R% 6 - = H & - X0 $+X T :; & 6 *i!, : -! !4 0h -N % % 23 $< 0+! Z - ,- X 6 0+ - - X- % > =H % $< -N I% & X0 - !. 1 ' > - X % X0 ( :F % X 0h -N & !, - -N 6 % X K! 0[b ' ,-N 0+ ' # X0 G ? 0+! Z j 6 X -> ' 6 0H 10 . - % ! . '? % ' 7> 0h -N 9 ! "# k` !3 5 d <F , k` !3 X + Z` 3 - NI $I 6 : 6+! X0 :c1 -7 * - 5 ! "# I % % % X0 - 1 ** a , I% % 0 -N[ : ? . ' ,d [1 $ X k !h - -N ! . % X0 96 P % %8 9C5 X 1 - ' > # :h % 0H g I % $ <Pc ' *)(0 ! "# VC $+X
  • 20. 2 k`% ? 0 3 0!7 $ % - %: % R% 6 -S 1 %Y ? . ' ,d [1 0, X :c1 E k L : 0* X R% ! 0[ d <F X l P 02 . R% ! ** , Y ? . ' ,d [1 : , 6 3 ' % Y N - n # _c j - 0 % :N m 6 X - 0 0 R% 9C5 10 ! +, ( % O% * ( $+X % - '( ** ', > d <F ' %8K! -N % ( Z 0 [ $ X :; * 0 Z% X 0 =< + % *-(O% * ( Vq $+X -H :; % ! ** , O% * ' ,( 9% 6 0 6 , 5 23 4 - P) D ' >c # ' X0 > o!# 8 $ - ( Z '%%p X f [P o!# &! M <P % NI _ S L '? S0 : L :h Z % X0 ?D -N %8 % X / Z 0 % p X '? % 10
  • 21. %( Z - :N - 0? % $!h m +3 o!# X0 ' %8K! 28 , % 10 $ !+ ! "# % & 6 - % X0 1 - $I Z% ( 1 ' %8K! d <F 2 X0 + ,6 X 6 X0 Z D & - a? 1 % 6 1 X0 f [P o!# &! - 23 4 '%% N % X6X % & - 2 % X K! -N & a? % X Z D ( R% a ? ' - 0!DI , - X0 Z D ' H R% 6 10 rPX - > a? Z% H- ' % X 6 ?> Z Z% < X0 / ' - F 9]5 X0! - [P $ < : c $ % 6 -0 - F 6 0 s ' ,( 0 3 % ? Z , Z% % O% * ' ,( ** 0 & 6 *i!, % : 8 k N 7 8 $2 % $!I % +S O% * ' ,( 9 X0 % Y, G H 6 !, % X/ 8t -5 1 ' Z% % ' > ' 7 8 0+ - ** 0 % Z% d H :[h 6 !, - % X0 Z D - # E :c1 % ' ' > 6 * X 0 ! X/ YDI Z% ( 6 *i!, : , ZD ! c 2 - 6N % [E 6 - : O% * J ! 0 ' 1 [ O [E w h % % : !, ?v I m NI YDI u - % / & –. > + =" m - N =" ' - '? [ R% 7* - : ' - 0 ,p ' - X0 h 0 cx Z X0 _? - X 1 - ! . '? % * h 8 0 a? : ) z1 % 9BAµm5 : *) 9y µm5 RBC 9@ µm5 ,: "# U * h '? - '( ' ,Y N -N 2 R% 6 0) [ b *h ! "# ' 9B@ µm5 :[h - 5 0) [ b *h Z ! ' % / ! YDI $ % +S ? :[h h 1 ? ' ? -D % 7 "# - - [ 0 cx ' 7 &S 9@5: ' N 9 , 0!
  • 22. U *X b % - : 6+! , ** 6 * N, 0 ,p ' - : & ' ,-) ) ' - $+c d% J X { [u $+X - 0) [ b *h % X / ,p G H ! "# X0 ,-) ) % X0 ' %8K! ,-) ) W) P :! $ * N, ' cx % ' % :P -F b b - , ** Z% J Fb0 |E % X/ , cx 6 p ! "# * 0 h cx % 6 6 ' %8K! F b 6 > :! X { [u $+X - ! . 0) [ ' ? % 10 ' %8K! 9@ ]5 10 !/ & $ % & 0' %& –- : '? * S [ & ' - X0 : L = } & % , > 6 ! "# - ' E X0 Y N2 0 ,- ` - % 8 : I - S0 [ 0 .% [ ' ,p ! "# -D X0 % [ 6 >* ' ? % - 1 . [ %D : L - F - XI % t F 0) [ ' ? -+ ) I X0 / = } ? % h [ ' ,p * 0! 0) [ ' ? - : 6 R% % 6 X0 ' %8K! 0 , [ 0 -D X0 % 8 ? ? 1 '% t S * ' ! '% 6 *i!, % ** ( k b ', > -N 2 +S ' ,p 9]5 s ', > -N 2 a? 1 : c # ! "# ' ? 0+ 0 P ' I [ ' ,& *+ 0 4 Z% & X ' ! "# [ X 01 ? ? ' X - X 0 [E ~ : 6+! +S ' ,p ? ] 99 ' c 8 [ 55 *h - ' b- ' c 3 % 0, ! "# '? % X 0 ' 7) [ ! "# R% 6 9@5 X0 ! . ' ! "# X/ ? ! a? X0 h [ *S & %( W[ P J R% 6 X0 1 ! - % X f [P 0 ' 7) [ - 8 R% 6 -S 1 X0 0) +) ' ,0 b % J * ' ,p , [ ^ * X # Y 0 P : [ . R% 6 ' 7 % F -[! : i # $!h 0)% 0 6 3 % ' : , > 6 J 0•3 / YDI % 0 b 6 - : : "# - 7 R% 6 0+ X 0 ' c I"b - R% 4 - Cascade filtration
  • 23. - - L ' cx % X ' %8K! : "# 0*x ' ! "# - b X0 Y ! "# 0! YDI : "# S0 ! "# R% 6 : 99 [ 55 [ 0 P ' 7X% > 0+ ** 0 O - 0? 0! !D -E2 - 0)% X0 % X 7) [ -[! ,' ! 0[P J ** O ' ,6 e % # 6 X0 ! "# % v % : 8 $g * !, : ' ,' ! % ! ' ,' ! , H 0•3 !* 0 48' 9 3 : ( 3 4& 567 21 % '% - ! X ' N # ' ! "# 1 + :[h - ! "# ' ? 0 P =^I : - N ' ,-* ?, % E - 6 ?> 3 ? D ' 1[ ', -[! 5 ! "# *, $ +c 03 H ' ? ! - : 6 ,R% 6 > 6 : -* ?, # 0[ . ' 7X% -N 2 0)% ** 0 ' 1 [ ' % I 9' 23 : ! "# 8 ' ? ! $ h - 0 ,' ! ' ,R% 0) [ b *h 8 - : & + 0 -[I $ X [x 0 P =^I ' ,R% % X0 h 0 P =^I > d" ! "# X0 & + ! "# $ % - c1 ' %8K! ! "# 3 10 =^I & ( ) ! 0+ ? 0 ! X G H - X - d< 0*3 X0 9 ( 5 ' > 10 G ? ! - k D : 6+! $!h 6 10 . ^ $I :F ! "# - 2 % X 8 d < 0I X k D % X h 0 P =^I > k ! N ! "# 0*3 5 X On–line < 6 $ 1 ' %8K! ! "# I % 0*3 5 X Off–line $+X - 9 1 f [P 0) [ b *h I% > ' # 1G ? ! - % 10 . ' $!h :F I % 9 0 - * 8 % X ' %8K! ' 3 X 0 € X - 0 P =^I ' ,R% J !A & ;< => & ' 7) +) - 0 - : ' 0) [ *, $ +c a? A 0 [ 6 e% # . IgG4 % IgG2 IgG1 ' . d < 6 e % # 6 9q5 d < & ( ) ! x < IgG A0 [ 6 e% # J % 9y5: u IgA IgM IgG3 8d< *0 q +[ –A0 [ 6 e% # % C % 18 – A0 [ 6 e% # % 5 - Staphylococcal protein A-silica(PAS)
  • 24. ' %8K! 8 ' ,6 ) [1 ! % X h , ! ' ! "# J % , $ . % X0! ' > J X & # PAS 10 d < ' ,6 ) [1 ! =^I 9q5 ! Q 3 ! "# ) T 0 7* , ^) X 0! 0 # X0 , ' - D* ^ ', K ht - ' d% %0 + % on-line R% ! "# - 2 '% $!h ' X0 : , Z% - ! "# % 0 + X J X - 0 >*, ! "# c . $!h :F ! "# O [E YDI -+ 6 : ' d I d% -+ ) I X0 + 1 d< 0X % 18 – A 0 [ 6 e% # $!h YN + - : 6 2h +[ – A 0 [ 6 e% # $!h YN + : 7 8 :X % ,6 ) [1 ! 0*! ' , +[ ! =^I - 8 ' ,6 ) [1 ! :X %"h 6 : i# X :X ' , +[ ! % ,6 ) [1 ! ? $ #0 ? R 1 %"h - 0 * N - R% 6 0 8 0 7* - % • N : 6+! 10 ? 0*! Y * D +[ –A0 [ R% 6 :X 0 ^# + ' -* d" - 0*! Y N n # - U 10 b YN + @ 6 YN 10 0*! O &S 0*! ' , +[ ! % Ud% YN + : N 0*! O d - -D % :N , +[ ! 6 =^I - . d [% ) + - _, ' 0 8 (0 8 - 4 , +[ ! 6 =^I 0 _ ? ' 0 8 - (0 8 10 K 0*! O % b ![ ! N+ A 0 [ 6 e % # - IgG d < b UZ% YN + : 6+! '% - ! D 1 - , ![ ! ' ? ) ^#0 1 0*! Y N Xd3 0H - 0* e % # X T % B ' 7) [ A0 [ 6 e % # UZ YN + X 0*! Y * %T B ' 7) [ g+ : 6+! ? 10 $!h y : 8 % ~ ', - Z% 2 ITP + [ VA‚0 [ 0* e % # 0* e % # 6 *i!, : - 1 . FDA v % 6 Staphylococcal protein A-agarose(PAA) 7 Idiopathic thrombocytopenic purpura
  • 25. ' , ** 7 ' - 0 ! FDA t % 18 V A ‚0 [ AV0 [ „ 0* e % # t - 0 ,' ! 9ƒ5: X * N, % : 8 & d% c FDA t *, % X0 / 'A & +< / & A B C= 3 #" ?@ *DEF(? , PAS Column(Prosorba) PAA Column(Immunosorba) Antiglomerular basement Chemotherapy-induced membranes disease thrombotic thrombocytopenic (Goodpasture's Syndrome) purpura (eg,mitomycin-C) Wegner's granulomatosis Platelet alloimmunization Focal segmental Solid organ malignancy glomerulosclerosis Systemic lupus erythematosus Paraneoplastic syndsromes Myasthenia gravis Paraproteion-associated polyneuropathy Acute demyelinating Autoimmune hemolytic anemia Polyneuropathy (Guillain-Barré syndrome) Humoral rejection of solid organs Off-label uses not approved by the FDA. L8 6 X%J : !, ' 3 0 L A0 [ 6 e% # 6 e% # 0X 0 L : % J m 0 U * h % 18VA 0 [ *8 ZD †TqV@A w h 6 N , … J 7 0 [+ "•h * h + [ VA 0 [ 6 e% # 0X 0 L8 : X ! †@yVqA% % N , & ( )8 ' ,_* % 0>* N , … J 7 )% U 9BA5 X R ?1 ! †yA % * Z D †@] ,_* % 6 ' 0 6 e % # - IgG d < X l -+ E !, X 0 3 w h 6 % ' ,YN + d 3 ' ? % % ,_* % 6 ' N X0 ![ ! N+ - D* A 0 [
  • 26. % 01 )8 $ X 0) ! I $[h : - $. ! - C5a ![ ! X ,_* % c * N, A 0 [ 6 e % # X - NX ? % 6 N % k .3 D 0 d H - :h BVT % I % *, 0 '% # :h & % W X R ?1 + [ V A 0 [ 6 e% # d j -[! X ' ,_* % : U * h R% 6 f X ' ,_* % rPc ' >) 7S ' -* ' ! X Y % % j ? s% h % : ) + % 0N " 8 !; 8 HI 3 = C; < G 8 3 4& 567 ƒ ' $!h 6 X 0 ? LDL 8 - Z LDL 0 P =^I ! "# Q 3 *, 0! n # 0 % - - > % , ? % > !, 0[ 0!)% N[ , LDL d% N[ ' N # 0 d % [+ % 8 K N - D* d" 6 %4 X0 ' ,' D*, K ,Z ?1 X 7 d% N[ >!cS _, LDL 8 Z D d '% !h d H _ ? % R % $!F _ ? ' % s% h 3 4 : N# ECG X 0 m LDL 0 P =^I ' ' 3 ' ,R% 9BB BT5 , 0 $ +c ' ? 6 1 ? 0+ LDL : BA- 1% - < ‡' L ! "# d% R% - 1% - < : ^# + LDL =^I ' [ 6 $ ) 6 !, - : ! "# *, d" % X0 $ % 6 0 [ ( G H ! "# h , 0! h LDL - - : &S ' I - 8 ' 7 - '> [ - )% ' ! "# - : N HDL †]y % IgG †qƒ 6 )8 †ƒ@ '% I X - < ' ! "# X0 0 -> (* †‡A IgM †‡T LDL †‡] [ $ 2 : ! 0)% X0 LDL d% N[ 07 c : - D* ! "# Q 3 -N 2 - 1% [ , 0 _, ! HDL 8 Low Density Lipoprotein 9 Secondary plasmapheresis 10 Double-filtration plasmapheresis 11 High Density Lipoprotein
  • 27. BT R% 6 : 6 ,t / LDL O LDL 8 Z% R% ! O LDL X0 %? ! "# - %6 , X $ ! "# =^I ? ) t % X O^ ! "# 6 , X0 [ t 8 #% & ~ X0 1 ! - % - c1 f [P 0) [ b *h ! "# 10 †Cƒ % †BC - (* % HDL _, % †@A _ LDL d% N[ _, 0 : c N % R% 6 X 0 B@ ) N O^ LDL =^I Z R% : X & + k" . - 0 ! "# % 0 + LDL d% N[ =^I ' k ! N ) J X # X0 1 ! - % X f [P 0) [ b *h X o!# d% d% N[ =^I ' d Aˆy NaCl d% % X : , Z% - d% D = < ' % - c1 # 6 ) d '% I 6 , 8 3 X0 - NX LDL & Q 3 d LDL d% N[ †C@ _, > c Y N 6 '% ,0 X0 8 : HDL d% N[ †C % ( * †@q _, ? % ! "# YDI B] ' , 7 '% I % YN 6 : 0*! O^ R% LDL =^I 8 R% %0 + : N LDL 4 - * 1 d [ 0[# ' ,' 0 8 - ` % d < % 18 6 X0 ' Z% *0 h & ! "# -+ ) I s * !, c ,0 X0 z - d < LDL =^I ' & [ ˆ6 N [1 z R% : HDL _ ? % BqC mg/dl ?z - d% N[ { I R% 6 0 z *, : X |4 m LDL 8 ' ,R% J T !X d% F ` ' HELP % ) N Y N t2 s ' ,R% LDL d% N[ 07 c _, *, c > + ,R% 6 -N 2 9ƒ5: FDA v ? ' ! _, > d I 6 h % ! "# ' ? % HDL ( * Lp9a5 6 ,_* % :h X 0 ! "# Q 3 -N 2 ! "# ' ? % (* HDL ** 6 3 J !D $ h 6 *% Z D 01 % -* ?, ‰ F) 0)% : - c ,Y N X 0 0b Y N 12 HELP: Heparin-induced Extracorporeal LDL Precipitation 13 Dextran sulfate absorption 14 Immunoabsorption
  • 28. %O K - X 0 "3) 3b XR S : 6+! & N[ ! ', - * d< 0 ' ,6 ` !3 $+c 6 10 8 % '7 )3 , 6 - ! 0 X0 d * %0 d xl ' ,d N '% b ' -c X ' , 7 '% I d" ! "# h : 6 *S 6 *, 0! n # 0•3 -S 1 % 0b 0 L R% 6 : R 7 Z d xl X# : ' 1 [ $ .6 ,6 0 _# - X0 & ( )8 ' ,_* % S !
  • 29. *"-#")( LDL : = CJ&K BK #. ?@ Method of Substances Removed LDL Advantages Disadvantages Removal Dextran Binding to LDL-56% to 65% Column can - Requires sulfate dextran HDL-90% to 30% be plasma (Liposorber sulfate based Triglycerides-34% to regenerated separation LA-15, upon 40% - High Kaneka, electrical Lp(a)-52% to 61% hematocrit may Osaka, charge interfere with apan) plasma separation HELP(plas Precipitation LDL-67% Removes -High mat Secura, of LDL by HDL-15% fibrinogen hematocrit may B.Braun heparin at an Triglycerides-41% interfere with Medical, acidic pH Lp(a)-62% plasma Bethlehem, separation PA) -Complicated system Membrane Separation LDL-56% Removes - High differential based on size HDL-25% fibrinogen hematocrit may filtration by filtering Triglycerides-49% interfere with apheresis plasma with a Lp(a)-53% plasma second filter - Loss of Some albumin, HDL, and IgG Immunoads Immobilized LDL-64% Column can -Exposure to orption(plas sheep HDL-14% be animal maslect, apolipoprotei Triglycerides-42% regenerated proteions Teterow, n B-100 Lp(a)-64% Germany) antibodies Lipoprotein Binding to LDL-61% Plasma Column cannot hemoperfus polyacrylate- HDL-30% separation be regenerated ion(DALI, coated Triglycerides-42% is not Fresenius polycrylamid Lp(a)-64% necessary HemoCara, e beads based Redmond, on electrical WA) charge
  • 30. / LJ 7; M ! ** , ' ! "# % RBC YDI 6 3 ! "# 0 $ N 0+ 9 - $< ' ,-) ) % > 5 / ? ' % F * - - : X0 Z D 990 Š 55 6 3 % 8 w h % N , ' 1 [ :7 YDI $ †BC / YDI D ? 0! . ' , h"H # - Z 1 0 $ YDI 6 3 ' - 9Bq5 * N 0 6 . % ` 3 ' 3 X0 Z D > t F % > - ! - f 78 %"h ' > % % % * m + % & * N, m * 6 !, - Y, % , 0 S: :N m ,: YDI u :[h - - ) :N, Y, . u $ X 03. % I ! 0 "•h k X % 03. % ? _ sS 0[ YDI R% ! ' I .Z - 0 7) $+c 6 - * 0 6 !P 9By5 * 0 6 $ YDI 0) . $ . 6 !P % X0 3 BV • 9 Aˆ@qq‡ ŒH 5 ‹ 9 AˆA@TB‡ ŒW 5 ‹ AˆAqA]B BV • 9 Aˆ @CqB ŒH 3 5 ‹ 9 AˆA@@Aƒ Œ W 5 ‹ AˆBƒ@@ 9 # - % UW Ž* - . UH ) - YDI UBV) * TBV( /?3 / L N J 7 BO # Patient Habitus Obese Thin Normal Muscular Rule of Fives* ml of whole blood/Kg of body weight)(Bƒ) Male 60 65 70 75 Female 55 60 65 70 Infant /child - - 80/70 Nadler's Formula (for adults)9B‡5 Male (0.006012ŒHeight in inches3 )(14.6Œ Weight in pounds)+604 Female ( 0.005835ŒHeight in inches3 )(15Œ Weight in pounds)+183 $ YDI †BC - / YDI % F ' - 9TA5 ', GH BAˆC 0*3 BAˆC mL/Kg X % / - : D - 0 2 g I ! ** , ' ! "# % RBC YDI : ! ** , % Z 1 [ , ' - 0 0 9TB5 X0 D* : !, % $ YDI m
  • 31. PV = BV [1- (0.91) (0.96) VCH / 100] PV: Plasma Volume BV: Blood Volume (liter) VCH: Venous Centrifuge Hematocrit U9TT5 %? ' d PV = TBV × (1-HCT) PV: Plasma Volume TBV: Total Blood Volume ! "# Q 3 -[I & - 0!DI 0*3 Q 3 YDI - F * - 0 ! "# YDI U9TB5 X0 R # EV Q PV PPVE Q 3 ! "# YDI & d 3 - 0 3 3 :PVE (plasma volume exchanges) X0 ) NI Q 3 YDI UEV X 6 ) - : 0 ? - ! "# % 7) [ $ X X/ YDI $ / RBC YDI % 9 * 0 Y, YDI 6 [x - 5 / - > ', N -S , : * ! : !, - * # -) ) % d Z - : 0? - ! - , RBC 1 _# ' c $ X ! ! : !, : N _ 0F4 % H - 0 / ' , RBC : N 6 * 1 .R # X TBV †BA : 6+! / $ YDI d g ' X / Y, / YDI : > Y ' , RBC YDI † BA _ -+ ) I $g Y N 0 * $ % % ' * J 9Z% O% * 5Y N J m 6 *S *0 u -[ % - & ** Z 1 / RBC YDI % / $ YDI ' : . 0[ / RBC YDI † BC –TA / $ YDI 1 9T@5 * % D 0[ YDI †BC ? c _, ' 1 [ ' 9` : !, ' ! dg *h - 5: †BC ! 1 : Z`' v[ v ) N 6 ) d [F ? D 0.% h $ YDI _, d - / RBC YDI X 6 # ! : !, †BC ! / $ YDI Y "h ‰ F) k 2 . ! ! %D / RBC YDI $ †BC : 6+! 0.% h
  • 32. X0 : "h %-X ' 0 [. "+c ' -iP ! 1 X :F 0N , / RBC 0!DI 1 9 •N - ' 0 0>* 5 X 6I : !, - F R% & * N, : "h % - d H d N1 ? ! U: * ZD V*RBC B 8 J 7 – /?3 U L RBC J 7( ÷ TBVT P "SSQ ?+ ; 7R C X 0 & )%%? : 34% & * Z D d" ! 8- , 0 c d 6 ' k ) x : : "h . ! % †T] _ '% N * ZD 6 I: !, 1 9@5 $!F - . 0 I 6 ? 0! 8 - " : "h . ! , P ( N ZD - *X 0 ? †T] ! : !, =? & ' [x ` :h 6 0 ` :h - ! "# * -!, _ % : 0 $ . 0E F % G H 9Bq VBƒ ? 5 j ? % & 0 0E F %- 0 Z h b -S 1 X0 d - 8'• ', % ' c, |E _, ! 5 ! :c 1 &! - ' % :c1 _ ? m % 0> N S % - X 0 "•h |4 % W34 - 0 7 8 % ! ' +!, Z h c, x E :[h - 0 , : '? % ' ^> - [x 9 X0 $+c 0+ ! 6 ?> '> ** , + b '? % ' ' > • *, : 6+! - : ( )8 0E F & v # !, _ # d [ :X 6 X0 1 h- ' %: *, - - 0 E - : |4 % X m 8 * • $ 0, 18 - : 4 *, % - 1 . - :. - 0•3 5 ' % ' , :F $ . - 0* ? ' ,' ! 0 ! "# : 0 $ . Y, ) x - : 0E F ' , % : )% Y, 9 .% $ X : '? %- 0 - -' 8 $!3 0 m -0 ! 6 *i!, ICU _P ' N ! %&* ? 6[ 1 Z * '? % ', ' ^> k` !3 9TTP 5 ! "# Q 3 3 - 9T] TC5:
  • 33. E _D* # % 0E F %G H ! "# Z D + - ' ', 1 . * 6 ' * '? % 0) ! I 0I H : g c ' % ^#= E3 '? ' , % ' 6 % BC 0) [ ** > t X D 0 * c :F Z • 0 , 6 *S X ' D ' % :P ', 6 * X0 #" S KE. d" % c * X 0I H ? ) 8 ' •% E - 0 - 0 % Hickman ! "# % ? ) !, Premcath. 5: * ! . 0 9T @59Quinton – mahurkar %Neostar pheres flow ' 1 . $F : h % 6 ) - P) D ' 1 [ ' , G. :. ' 6 ) $ - ! "# Q 3 Z ! # -[b " -* , d [F G ? : Y7 8 ** d 3 ' ,% G ? - P) % b : - P) D ' 1[ 6 ) D ' . % - P) X ? ) - D* k` !3 - P) '% I 6 ) - ( * ! "# 9Tq5 X0 $b I w h % "+c 6 c % 3 '? ', E % : Y7 N '?z ' , ' ^> 9Ty5: , 6 !, 0X ! "# 90 . = %5 SVC 0[ ` 1%( % % 6 %" O z • - :X :. m ! % : ? [, • 6 1 . b X c : ? [, %% j - D* 0 - * 0 % 9PVC5 0*E m - 4 % 0 [. 0! 8 SA node % 0X ! 2 N 0 X0 0! 8 % - D* - 0 [. & F 9Tƒ T‡5 X % % 90!) , 0!N[ ,5 0 )% +) u 3 & F 0X Y 2 N x & X ! [. : ? [, $ - 9 X0 ? Y N[ - - 5 2 %"h X ZD 6 %" O '? % ' ^> # -* -N . 0 1 % Xp Z h 90 . = %5 SVC • ' 1 . * !H d <I Y, X , 0) 8 % *# !, - D* 0 - t 6 %" O 9@ Tq5 1 $b I * !H , 8 ' 1 . $F 6 7 '? % - 3 - Y !< l P $ . 0I -E % ' % 0 X :*X & - 3 ! 0•3 ' 9@5: 1 Y !< M ! d ! %% X6 0 . V0 . - I : # - 6[ % [ 0[# #& * 15 - Soft -walled
  • 34. Z ` * - 0` H ' - ! "# 0 ' ,Q 3 b< X0 $ . 90 F = %5 IVC • - d ! - I ', *S , 9Tq5: % _ % - , & g I - ' E : 78 0` H K : h % 10 0, 1 0 I: % F % X ' N ! ! k *!4 % X & g I - ' E * N, * ! 0` H ' , ' 6 %" O ' , ! 8 3 - % X . 0 Y % & g I b 8 X % ) 1%( % '? %- 0 :7 1 : 03 H ZD ! "# 0 , 6 - ) - 0! c ! / , p ' 1 . $F : h 1 ,s -[ - *.-(= ? =C & W M #- ?@ Catheter Advantages Disadvantages Site Femoral Placed at bedside Increased risk of infarction Requires least skill to Decreased patient mobility insert Risk of kinking Hemorrhage easier to Risk of arterial puncture* control Increased risk of thrombosis No risk of pneumo/hemothorax Subclavian Patient comfort and Hemothorax/arterial mobility puncture Long-term placement Pneumothorax Requires greater skill and technology Cardiac arrhythmia(position of tip) Subclavian vein stenosis Internal Patient mobility Risk of arterial puncture* Jugular Long-term placement Cardiac arrhythmia (position of tip) *Using a cutdown technique instead of percutaneous
  • 35. !X3 + 1. Hodgson WJB, Mercan S. Hemapheresis listening post: optimal venous access. Transfus Sci. 1991, 12: 274. 2. Winters JL, Pineda AA. Hemapheresis. In Henry JB(ed): Clinical Diagnosis & Management by laboratory Methods. 20th ed.WB Saunders, 2001:776-805. 3. Hillyer CD, Silberstein LE, Ness PM, Anderson KC. Blood banking & transfusion medicine.Basic principles and practice. 1st ed. Churchill Livingstone, 2003:509-518. 4. Burgstaler EA. Current instrumentation for apheresis. In McLeod BC, Price TH, Drew MJ(eds). Apheresis: Principles & practice. Bethesda, MD, AABB press, 1997:85-112. 0+X?# d2 d b - * / ' !I Z ' P Z ' % >*) ' , U 8 0S Eh VC y@qVqƒy-F b Z% [ d2 6. Matic G, Bosch T, Ramlow W. Background & indications for protein A-based extracorporeal immunoadsorption. Ther Apheresis. 2001, 5: 394-403. 7. Pineda AA. Immunoaffinity apheresis columns: Clinical application and therapeutic mechanisms of action. In: Sacher RA, Brubaker DB, Kasprisin DO, Mc Carthy LJ(eds): Cellular and humoral immunotherapy and apheresis. Arlington, VA, American Association of Blood Banks, 1991:31 8. Mcleod Bc. Therapeutic apheresis: A physicians Handbook. 1st ed.Bethesda. AABB press., 2005:163-180. 9. Levy J, Degani N. Correcting immune imbalance. The use of Prosorba column treatment for immune disorders. Ther Apheresis Dial. 2003, 7: 197. 10. Huestis DW, Morrison F. Adverse effects of immune adsorption with staphylococcal protein A-columns. Transfus Med Rev. 1996, 10: 62-70. 11. Bambauer R, Schiel R, Latza R. Low-density lipoprotein apheresis: An
  • 36. overview. Ther Apheresis Dial. 2003, 7: 382-90. 12. Bosch T, Wendler T. State of the art of Low-density lipoprotein Apheresis in the year 2003. Ther Apheresis Dial. 2004, 8: 76-9. 13. Parhofer KG, Geiss HC, Schwandt P. Efficacy of different LDL apheresis methods. Ther Apheresis. 2000, 4: 382-5. 14. Hershkovici T, Schechner V, Orlin J, et al. Effect of different LDL-apheresis methods on paramethers involved in atherosclerosis. J. clin. Apheresis. 2004, 19: 90-7. 15. Matsuda Y, Malchesky PS, Nose Y. Assessment of currently available LDL apheresis systems. Artif Organs. 1994, 18: 93-9. 16. Standards committee of the AABB: In Menitove JE(ed): Standards for Blood bank and transfusion services, 18th ed. Bethesda, MD, American Association of blood banks, 1997. 17. Mollison PL, Engelfreit CP, Contreras M. Appendix 5 in Blood Transfusion in clinical Medicine. 10 th edition.1998:561. 18. Gilcher RO. Apheresis: Principles and Practices. In Rossi EC, Simon TL, Moss GS, Gould SA(eds).Principles of Transfusion Medicine. 2nd edition.Lippincott Wiliams & Wilkins, 1996:537-545. 19. Nadler SB, Hidalgo JU, Bloch T. Prediction of blood volume in normal human adults. surgery. 1962, 51: 224. 20. Standards committee of the AABB: In Menitove JE(ed): Standards for Blood bank and transfusion services, 18th ed. Bethesda, MD, American Association of blood banks, 1999. 21. Buffaloe GW, Heineken FG. Plasma volume nomograms for use in therapeutic plasma exchange. Transfusion. 1983, 23: 355. 22. Kaplan AA. A simple and accurate method for prescribing plasma exchange.
  • 37. ASAIO Trans 1990; 36:M597. 23. Jones HG, Bandarenko N. Management of therapeutic apheresis patient. In Mcleod BC, Price TH, Weinstein R, eds. Apheresis: Principles & practice. 2nd ed.Bethesda, MD: AABB press, 2003:253-282. 24. Rizvi MA, Vesely SK, George JN, et al. Complication of plasma exchange in 71 consecutive patients treated for clinically suspected Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome. Transfusion. 2000, 40: 896-901. 25. Annane D, Baudrie V, Blank AS, et al. Short term variability of blood pressure and heart rate in Guillian-Barre syndrome without respiratory failure. Clin Sci(Lond). 1999, 96: 613-21. 26. Gilcher RO. Apheresis: Principles and thechnology of hemapheresis. In Simon TL, Dzick WH, Snyder EL, et al. (eds). Rossi's Principles of Transfusion Medicine. 3rd ed. Lippincott Wiliams & Wilkins, 2002:649-657. 27. Spindler JS. Subclavian vein catheterization for apheresis access. J. clin. Apheresis. 1983, 1: 202-5. 28. Sutton DMC, Cardella CJ, Uldall PR, Deveber GA. Complication of intensive plasma exchange. Plasma Ther. 1981, 2: 19-23. 29. Huestis DW. Risk and safety practices in hemapheresis procedures. Pathol Lab Med. 1989, 113: 273-8.
  • 38. %"#$ ! " ! "! Plasma products by donor plasmapheresis Therapeutic plasma pheresis $ # & '# Plasma products by donor plasmapheresis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…… @+ ! " =^ @ ! b 1 %a` 1 "_ @ 74 89 ! )? ! ! ! :; '( )*$! ! W 4 % + c ? ! +! "! ? + ! ; D! $ V1 $ !! " +! "! ! A 89 ?3 d ' U ! # A 89 " P D C K @ ) + ?3 A ? + V ?$ 74 89 4 @ ) + e ! $ ? ! @6! U 74 89 f
  • 39. '! 'N +! "! C?6 h " " g 'N +! "! ) "I +! I" + i % + c [ 74 89 $ 6 74 89 P D j %7654 - 3 1 $ 2 + 1" - ./ 0 *#, + *# * 765 - ./ 0 *#, & + 83 2 + Procedure Instrument Primary PLAP MCS +(LN9000), Spectra, Trima, CS-3000, Amicus, AS104 PLAP + Plasma MCS +(LN9000), Spectra, Trima, CS-3000, Amicus, AS104 PLAP +RBC Trim a 2RBC MCS +(8150) RBCP MCS +(8150) Plasma PCS-2, Autopheresis-C Granulocytes MCS+(LN9000), Spectra, CS- 3000 PBPC Spectra, CS-3000, AS104 Secondary Cryoprecipitate PBC-2, Autopheresis-C Cryoreduced Plasma PBC-2, Autopheresis-C PLAP%Plateletpheresis; RBC: Red Blood Cells; 2RBC: Double Red Blood Cells, RBCP:Red Blood Cells plus Plasma; PBPC% Peripheral Blood Progenitor Cells.
  • 40. % & = $ N ! E " 23 "@* ! C " 2 k @9 0 ! "! ' &-. ! =@ ! W 4 % + ' 6 ' N +! "! ! + @ ! ; % 1 0W 4 7 ; %E! K b 1 W V$! +! "! 2 k = $ ? D? ! Z6 ! "! + ! !/ ! "! P 86 Z6 'N +! "! _ l W F M . ! 0' N +@ ! Z6 O 8 = %E $ n1J / ,-. ! @ ! CU 0 ! 7 ; W V$! 3 0 U1J mY l6! ! 0n1J / ' 1 ? l ! +! "! = 1 o 8 ! "! ! 3$ ? l = $ : ! ! &?+ $@ L 0 ?K! 7! Z6 %K! -+ ! % + " N ! "! ! W 4 ' ! I , ! + @ ! B E egpfg K W V$! 7 A . +! "! ME J $ $ C! = 1 0@ ! B E qp # K +% +'6 0 ABO/Rh%r 1 1 @ ! r6 +! "! ! 4 ; + 3 = ! -H K 0^ -) RPR 0 HTLV I II pAb 0HIV 1 2 Ab 0HCV –Ab0 HBs–Ag0HBcAb =^ 1 0^5 6 ! ?$ 2 k ALT ' N +! "! = ! 2?* ! "! 7 ; ! ; 0 +! "! A &E " ; ! :; %E! K = $ ! "! A ? g ]+! K A & #f $! ?)" 7 ; ! ; ]+! K C m " 0 1 @F fq ! ? + &$ *-D $ -H [ ]+! K ' U ! * B + =^# 1 ^ ? # f ]+! K [ =@ ! ?3 0% + ' 6 ! "! 1 $ U k " 0 + ! "! 0 ?)" [ " ! I %H! N! ! "! ?)" [ " ! ? + %H! ! +! "! N! = 1 % + ' 6 ! "! " ; D! / C; $ t! U 0 1 H 6 " ; D! 1 $# U s " 0 $ A ; U 'N " W W C u %E! K U ! D 1 ; n1J W W Cu @9 ^ &U [ " KC ; $ %H! 0 1 igr/dl ' N +! "! $ W J ! =^e $ N ! E v + '( ) $ ! ?U ! _ C & 0C & ' 1 % & ! 1 6a P& +C + ! K 1 Infrequent 2 Frequent
  • 41. ]+! K ' 3$ D $! 0 ?*" ^IX ?+ VIII ?+ 0 %6! C -N $ ! =^ $ ! "! % + iRRcc " ?)" OVK M E A ? + @* $ C J2 D 7 ; ! )? ! $ t4 ; ! "! 74 ; M . ! + 0@ ! W 4 ' 6 OVK 1 Q w ! F ! N -D ! ' ! 1 x 6 &$ Ny " . -+ Z @ ! & 9 % E -+ A H! +l = 1 ' 6 OVK %+ z g ! I ' ! x 6 ' 6 OVK % ./ 0 & & " 1 b $1 O *B -+ N ! "! 74 89 e V 96 f P& 9 (FFP 5 :; & ! D' !% +' 6 P D ! @F i–q ]+! K + @ ! % + ' 6 P {JD 0FFP 7 8 ^ ) ! 7 8 $! . =@ ! 1 V t ; A D= 1 P D ^ " RBC ?+ W| t ] [ 0 " ' D ^ ! " RBC RBCP 7 8 $! +! ! VK ]+! K g b " ' 3$ 0 1 P D +! "! @ + " ' D 765= *>#'- ? 2#@ ! & 1 ) 8< 2 + Donor Donor Maximum Absolute Weight Hematocrit Red Blood Cell Maximum plasma (Ib) (%) Volume (ml) Volume (ml) Men 110-129 38 185 450 130-149 38 195 500 150 38 210 550 Women 110-129 38 180 450 130-149 38 190 450 150-174 38 190 500 175 38 200 550 3 - Fresh Frozen Plasma FFP 4 - Source Plasma
  • 42. '! U ! - D != ! !J % + ' 6 ! %H K FFP * B 1 FFP ?U[ + " K! ! ' } + ,*+ " n ! ! iRR– jRR K g • O VK ~'! F ! OVK W + % & % + ' 6 ! %H K FFP B 3 ;? " " $ N 7 V I" + 0O VK " K! C ! = + V '! € ; ' D A ] '! F FFP ! 4 "OVK $ + @ ! $! ?1! )? ! + 4 89 '! _ C!n + C! F =^ $ ! TTP6 ?& ! %H K FFP =^f ! I !J ! ! IgA E FFP AB N FFP $ ?*" $ =@ ! 7 )? % + ' 6 ! %H K FFP X 6 89 7<5 - . B#, $ C & 8A 2 + Whole Blood Apheresis Red Cells Derived Fresh Frozen Plus Plasma Plasma Volume(ml) 200-250 500-600 450-550 Plasma (%) 80 90 90 Anticoagulant 1:8 1:16 1:16 ratio Anticoagulant 3% citrate 4% sodium 3% CP2D type citrate Citrate content 0.60 0.40 0.30 (g/100ml plasma) Adapted from Gilcher) 5 Jumbo Plasma 6 Thrombotic Thrombocytopenic Purpura
  • 43. C! B;$! L K ! " X 6 ! ?3 '!J D ^ % + ' 6 ! %H K FFP z qR % B ! %H K FFP z•R 74 89 2 1 ! W4% + c n = 1 7! ? J+ -N ? + '!J KC m "= ! 3 2 " ?+ & + 7 1 ]D D + @ n . $! M J ?1! $ B;$! @ ;L ‚ 0M J A &$ $! A *N J '! B;$! CU ƒ* C ! 0@ ! ? + ! %H K FFP D WBC @+ ! ; = 1 / %6! ? U !JD! "C + ? ! ! %H K "I +! I" + @ ! =^j0q 1 O $ N ^Passenger * "@ U ! %H K ' ?} ! + V ?$ 0 ! %H K @ ? } !+ = @ 0 ! % + ' 6 ! %H K OVK ! A ; VK & k + j ME $ ^d. ! + ! RRcc K VK _ C ! @ @? } !+ 7 H % + ' 6 ! %H K ! + U K =@ ! M J d a % E $ ?1! $ ' 1 q $M J ! I ' 1ME ?1! g– #R A ; VK n36 !+ =^• ! € ; C J2 D P '! F ?1! fRR cc K VK 0 ! + E =^ R ! + TTP ?& '! 0 $ % (Source Plasma ) D@; & 0C & $ ! x! Y? ! % E 74 89 !+@ ! 0P& 23 4 0 " 23 "o ; B;$! " ?+ " ?$ * + 0 "C -N $ ! = 1 PE! )? ! '6 • % F C ! k D! A &$ + @ ! A ; k C ! _ C -N $ ! J V '8 ! ! $ H 8?6! "C -N $ ! ! = N 7 H !J K ?1lN ' *+! ? ! ‚! @ ! CU + @ ! ^C -N $ ! K L 0 „$ &-. ! ! "! % …! ' D 1 $ ?$ 7 Wet cryo 8 Dry cryo 9 Passive Immunization
  • 44. 7 H $ 1 (! ? $ ?$ G 9 ! ! ! C ! = $1 *+! $ = 1 )? ! "C -N $ ! x! Y? ! @ D $ !0 $ B ? ? *K ! "I +! V t4 ; + @ ! D O" ^ & ! $! K S $ Ig ! , k = $ 1 RW %7665 * F $ G 1H $ C & Ig E) 7 Anti rabies plasma 5 &1 B# I & / ' 1 JN > ! *+ ! ^ HRIG $ *$! " C -N $ ! ' ! " ^ ! ?$ I" + ' *+! W F C ! k ^ " '! K 4 ? 0 " L C*+! C -N $ ! , + = ! + 0 " C*+! J V O6 ;L = + V! + ]6 " ?$ ! ? } 0 1 *+! #qp fpjpepR " 0 " ' !} " „ ! 1 V ?$ ! $ B V ! ! ' .! A 8K ?$ 0 1 l6! " ! $ ! "! 0 1 H O %H! 0/ ! 1 ' ! ! 7 H = N " L H 8?6! C -N $ ! %7 TIG 5 B# I & 1M J '6 D O ! O ] 6 ! ^TIG $ *$! !J+ C -N $ ! @ ! W -; $ ?1! $ D ' *+! „B + ! TIG =@ ! ‚ * ! TIG = 1 J V O6 ;L "' !J+ C*+! ! " 0@ ! † ]+ O6 !E ' *+! @9 + $ &-. ! ! $! 1 *+! !J+ L ?1lN + ! ! = 1 ?$ ? + B D ! 0 $ N %B4 I B# I & fq . ]+! K B @ }" > C ! k „ D! ! B @ }" C -N $ ! 1 +a O" @F j# P 6 = 1 J V @ }" C*+! ! " > ! @F HBs Ag '! ! ? '! ! $ C m " =@ ! ‚‡ 0 1 M J P [ " ? 0@ ! C -N $ ! = 1 J V C*+! ! " 0 ! $ ! @F # . + ! + @&] B @ }" 9Z '( ?$ -F ?$ ! 4 F + ! ! ! B @ }" H 8?6! = 1 0 $! 10 - Serum Sickness
  • 45. % Rh J H '# # !#*# ! 0 $ ! @&] Rh C D + ) Rh '! ^W N A } Rh L C -N $ ! V + 0C D /B ' ! A &$ C D D '( ?$ @ *K V ! ! N -D C D /B ! 23 ! = ! + 0 1 @&] Rh "C D ; U "/B ! 1 W V$! K %6! ' 6 A B?$! $ € ; 0D '( ?$ > *K "O$ 6 = 1 Rh L C -N $ ! 0 $ ! 1 ,*+ W 2 k ! =@ ! ' 6 N "W ?$ „ P& " + 2 ! 1 d Y?$! , F ! !0 $ 6 " N ?$ S $ G 9 ! 0,-. ! ! ! ' M J = 1 )? ! Substance A B AB ! F I !J ! ! ! :; = $1 =@ ! S C "O$ 6 ' o 8 0 V &U /B +! "! " ! . B#, B ! ;; 1" N# O * & L; M# $ 8K 2 + 765 *#, & + REACTION Whole Blood AFFP Vasovagal Occasional Rare Hypovolemia Occasional Rare Allergic Very rare Very rare Citrate effect None Rare toxicity None Very rare 11 - Intrauterine transfusion
  • 46. & P1 #Q ! "! $ ^ '6 !JD! ' N +! "! ! "! ! 1 $ d -Z $ "I +! '!J =@ ! % + ' 6 ! "! ! ? + , ! AFFPb apheresis fresh frozen plasma; Occasional: 0.5% to 2.5%; Rare: <0.5 %; very rare: <0.10%; Frequent: 5% to 20% ' ?* D @ ! ?3 , ! A ! ' N +! "! d -Z $ "I +! S E =@ ! ? + , ! $ A N! ! I +! S E A ?K! 0 $ 1 + " +! "! * B " +! "! % ^ } " ' 6 OVK I" + ! ? +t& k . 1 x 6 ' 6 -+ OVK t4 ! =@ ! ? + % + ' 6 " +! "! = 1 '! &D C J2 D "A -9 $7 H ? @ ! OVK @ ! % + ' 6 ! "! 0% + ' 6 ! "! * B W V$! C K +! "! @K! ? ! $4 . t ?&*$ ' t $ ‚ = " ! N V ' + s D! : D E F x 6 !JD! =^ #0f 1 ' K$ W " ' N +! "! C L FC A! ? =^ 1 $ % + ' 6 ' N +! "! ! I W " $! ! '!J C ? =@ ! $ * ! "A -9 @ @&*$ n ( "I +! B;$! L s '! F + @ ! 7! ? B;$! L s 7! ‚! ˆ & ! ?$! „L F s $ E ' $! N ' D O" ' ! 3Y 1 )? ! ' ! x 6 O?* D 7! ? ! 1$ O F A ?K! = 1 ' 6 ' D ! 0 +! "! $ 6 !JD! =@ ! ?3 0 ? + ' ! +! "! > *K! ' 1 0JNJN _ > *K! 0' " *K 7! ? † )6 I +! I" + $ s " ' 3$ 0 ?* $ +'! 2$ 7 H $^ 2? N "I +! = ?*" 7! ? @ * DO F ! 23 ! 0 W V$! @F ^> $ ? ‰! )? ! 0S 0' %+ _ 0 $ :F Š ! + 7! ? @ * ! 1$ 1 ' $! N @F I" + $ D ! * B $ $ * A &$ ' + W N O *-+ 0 +! 6 " ! ?$ J V = $ ! +! "! 7! ? K 7& + H -+ Z O *-+ K "A -9 J V = + n + O F I" + O" +! "! R ! B 1 1 $4 . 3 ; k Z "I +! + ! 2 0 1 $ ? 1 J V B E gp R . 2?*" 7 8 z R O *-+ 7 $ + -N =^ f0 e^ $ M J 2?*" $ME @ U ! O *-+ 7 $ + -N @ !
  • 47. ! *$! $ A U $ U @-F n ! 3 " t & B 0S E 7 H " 7 $ J " = $! 1 1 $ RBC K " &*$ % + b@ ! * 0 %-F 0, ? ' x 6 C $4 . ' 96 $4 . 7 ! '6 ! 4 ' D $9 d O+ %H! ! "! 9 R =W ! ' D "C 1 ! )? ! 7 H ! $93 ! )? ! + " @ ! CU ‹ ' ! 1 $ , '! F &+ & 0 "! Y$ % + ' 6 ! "! ! I 0 $ ! $ ! n + " 2? ! 0C B F d 8F! , " Œ t $ -D d 8F! ", =@ ! $ ! ! ?U[ + $ ! )? ! ( U @ 3 = 1 $ JN " t & B ^ A ! # ' ! 1 x 6 ' 6 OVK =+ "! 6 n + 7 U3 C ! I" + 0 ? % =@ ! ? I" + 8Y3 Z D % ! )? ! t& k @ ! ?3 , ! ECBV0 + + d ? ' D + "C 1 T E = + $ V ! -U3 0A ).! $ W V$! ! JD W V$! C K +! 6 7 ; ! )? ! ^ ! 6 @3 " +! "! N ! E @ ;L = " I" + ! 7 U3 0 ! %H K " WBC ! ; D @-F W V$! „ ! "A C ! 6! = %:; n ! „ K C? @ ! "@ ) I" + " +! "! ?K 0 " WBC ! ; I" + " J+ %U3 =^ g@ ! 1 P) W V$! + %H! ! I ?F B;$! " ?+ "C -N $ ! @1! " $! 2$ ?1lN ! + $ N +! "! 7 $4 . " + @1! D $ J2 D =@ ! &$ < ! s + ƒ 0 $! ?1! ! "! 12 - ECBV Extra Corporeal Blood Volume
  • 48. %D ; 1. Gilcher RO. Apheresis: Principles and thechnology of hemapheresis. In Simon TL, Dzick WH, Snyder EL, et al. (eds). Rossi's Principles of Transfusion Medicine. 3rd ed. Lippincott Wiliams & Wilkins, 2002:649-657. 2. Randles MJ. Selection and care of apheresis donors. In McLeod BC, Price TH, Weinstein R, eds. Apheresis: Principles & practice. 2nd ed. Bethesda, MD: AABB press, 2003:131-142. 3. Stands committee of the AABB: In Menitove JE(ed): Standards for Blood bank and transfusion services, 18th ed. Bethesda, MD, American Association of blood banks, 1999. 4. Winters JL, Pineda AA. Hemapheresis. In Henry JB(ed): Clinical Diagnosis & Management by laboratory Methods. 20th ed. WB Saunders, 2001:776-805. 5. Smith Jw. Automated donations: plasma, red cells, and multicomponent donor procedures. In McLeod BC, Price TH, Weinstein R, eds. Apheresis: Principles & practice. 2nd ed. Bethesda, MD: AABB press, 2003:147. 6. Gilcher RO. Novel hemapheresis donations. In Capon SM, Jeffries L, Mc Leod BC, eds. Selected topics in hemapheresis. Bethesda.MD: American Association of Blood Banks, 1996 7. Heddle NM, Klama L, Singer J, et al. The role of the plasma from platelet concentrates in transfusion reaction. N Eng J Med. 1994, 331: 625-628. 8. Brand A. Passenger leukocytes, cytokines, and transfusion reactions (editorial). N Eng J Med. 1994, 331: 670-671. 9. Smith Jw, Gilcher RO. Red blood cells, plasma, & other new apheresis drived blood products: Improving product quality & donor utilization. Transfus Med Rev. 1999, 13: 118-123.
  • 49. 10. Owens MR, Sweeney JD, Tahhan RH, et al. Influence of type of exchange fluid on survival in therapeutic apheresis for TTP. J. clin. Apheresis. 1995, 10: 178-182. = U1J ' 6 A B?$! A H! =x K! 0W Y? ! 0W 2 " b = = [ ZF =jeipiqj 9)H =W -D ='! ! ' 6 A B?$! ' 12. McLeod BC, Price TH, Owen H, et al. Frequency of immediate adverse effects associated with apheresis donation. Transfusion. 1998, 38: 938 13. Hester JP, McCullough J, Mishler JM, et al. Dosage requirements for citrate anticoagulants. J. clin. Apheresis. 1983, 1: 149-175 14. Oslon PR, Cox C, McCoullough J. Laboratory and clinical effects of the infusion of ACD solution during plateletpheresis. Vox Sanguinis. 1987, 33: 79-87 15. Strauss RG. Effects on donors of repeated leukocyte losses during plateletpheresis. J. Clin. Apheresis. 1994, 9: 130-134.
  • 50. Therapeutic PlasmaPheresis TPE Therapeutic Plasma Exchang ! ! TPE "# $ % & # ' (& )*+ ',$ - ./ $ 0 1 2+ 34 & 5 ! 6 7 ' & > 3 #? " 89 # #:;< 0& * = > - ! @ ! 6 7 - ./ $ 0 5 *; "& ,8 !" # $ %& # '() * + , I2+ 5 *; % " : CDHF G & & CDEF AB ; " & UC S TR Rh P Q+ BI 7 J & '?#K GL! M & - 8N O # @ ! ;?#K L B # 34 & UV WRUSLERC % ;Q ; P " 89 " 7 ] #K ^ L &# % $& & 0X ;7 - Y Z 8B [#; $& @' 5 5 - cd+ 3 _( & 8 , ; " L & ` a "b ; ?% Z 9 @' 5 ! "7 e ! B5 6&#7 Z $ 8 J#? TPE ;!dK #/ 8N #B ' ;? 0 # f e & "&#a Z & ' & $ h 7 % 8L % " 8 TPE `a & &@ $& e ! Z g+ ;9 @' 5 ! + # X L "& '! # ',$ 8 " 6 7 "7 # 9 " 7 ] #K K. , L # $^ i Me #j M e "& 0 # 9 " N & J ' #;, .;8 '9# ^ + - 9 & X ; Q ". 0 > d 8 ^ a&#9 6 7 & G7 g? - ' X L @ ! 8 n G a # &5 !5 & Il8 ^ m TPE k '! # p ! o#e # M 0X U TPE R 8 J#? r' $ "b G 9 J q C r ! ;! m :7 N TPE k '! # G a "b Z q S r' 8 n G a '! # J JqT 1 - Systemic Lupus Erythematosus
  • 51. r' /N TPE 5 ! '! # Mm G 9 L " 89 B Ig 1 g 0 m :7 q V r !6 7 " . N TPE 8 J#? M+# #B q W r ! Y 2 Mm ? N TPE 8 J#? q E r' M+# 8N G ! TPE 5 & % q H r 8 & L TPE 8 ./ $ 0 1 qs r' ". N & (Z 1 NqD r' B / J B # N TPE 8 J#? qCF r ! Y2 Q N g+ & U " 7 % "; R M> N TPE q CC -. # / 0 "1 2 3 4 & U% ;Q ; P R SLE Gt B " #K L J " 7 ] #K ^ L &# % $& & 0 m :7 - [#; $& Rh P Q+ BI 7 & ' 5 5 - cd+ 3 8 , ; " L & ` a "b ; ? % " 89 o#e e & "&#a "7 e ! B5 6&#7 #l " B G L #l - " @'Q ! B ;J G ! ] #K B^ L &# `a & e ! B5 - A B- Q & M % B5# 2 B- MK # 8 B3LM4 % b ! 1 - '! # `a & TPE Mm ga @ ! @@@& ^&#;QM & + B- u &# 4 @ PL & v J &# B 5 $ & 5 ! # K M$ " #; v J , J nB G R ^ M& L I;Q ?( G > # K M$ " "J Z ? #/ " ' ',$ ; *8 , M % #> U" 7 " #$ G7 B- Q '! # ' " 7 " #$ ! #K n .? #e7 "& 2+ # O . "L & ; Q Q ; @ 5 ! S ' -L O . "J 'Q J ' I, TTP " 5w ' x. - #7J @ ! #j 8 # K M$ ; ` 2 ;? nB ;? ' ; ? "# $ G I Q 5&#K 8N 8;QB $ $ "b G 9 pUER ! 2 - Thrombotic Thrombocytopenic Purpura
  • 52. & ; J 38$ B GL " : ' m 7 'M9 B^ L qC T GBM ( ;J 3 & #K 8; $ B ; J 8 @ 8;QB ;J @VIII ; ? B5 88 , & TTP % 4 ' L & SLE 8 88 GL 2 " 7 2 ; & L . ? B Kw & B^ L qS W V B3L4 0 : 5w ; J 38$ vM # " ! G+ Y 9 & " 7 'lM n .? 8 MK&# & Y M G4 ; ; LQ &#4 B Y 8 , L - A @ 8;QB 8 @ $& Y#;! " & E I &#;QM #4 B LDL 8 8! k # 8 I;Q #g , L qT - Q cd+ y&# " ? t ! B- u &# & UAmanita phalloidesR TPE # - @ . $ "b G 9 cd+ 0& *; # % TPE H I2+ #K 2 "& & - ./ $ 0 O# 5 ! cd+ ; ? " # - ./ $ l8 o (& 8B ; @ ! 5 *; " " TPE 8$ - TTP @' $ "b G 9 % 6&#7 ! TTP " TPE ' t #j ' 5 h< #B & ' $ "J ; ` 2 Z 88 , ; ? 8 ./ $ @UHR' - & 3 - Glomerul Basement Membrane Antibody 4 - Hyperviscosity 5 - Cold Insolubility 6 - Low Density Lipoprotein 7 - Volume overload
  • 53. Table 8-Indications for Therapeutic Apheresis Generally Accepted for Reimbursement by Third-Party Payers 5 Plasma exchange IgG Myasthenia gravis Eaton-Lambert syndrome Goodpasture syndrome Myeloma with renal failure Guillain-Barre syndrome Hemophilia with factor VIII inhibitor Chronic inflammatory demyelinating polyradiculopathy IgM waldenström's macroglobulinemia Cryoglobulinemia Hyperviscosity Immune complex Glomerulonephritis, rapidly progressive Rheumatoid vasculitis Metabolic diseases Refsum's diseases Hyperlipoproteinemia, familial Cholestasis- intractable pruritus Diseases of unknown cause Thrombotic thrombocytopenic Thyroid storm Scleroderma, refractory Polymyositis, refractory Cytapheresis Acute leukemia-debulking Hairy cell leukemia-maintenance Thrombocytosis, symptomatic Chronic myelogenous leukemia, acute symptoms Red cell exchange Sickle cell disease Ig, immunoglobulin.
  • 54. - ,8 0 +&8# : ;< += , 0 TPE 7 .8# 0 20 9 "1 6 TPE k "J '! # ! # 0 m :7 $ "b G 9 m p ! ;! 8 jJ "J L " &R ! ^ L &# + &z. ? + ! '! # 5 qC " #;M ? B # l h 7 #" B% 8L J e U ! CWFFF n @ ! '! # G a High Flux . B - 8N " 6 7 '! # e ! X ;Q # 9A 5 ! '! # Z qS IgG ^ t # @ ! U IQ ; R , J " G7 Q # Q #`# Q 5 3 $ ;J {a & B # " 0 m ;+ 5 & SC # # 9 "J # ` # cd+ ',$ - # 8 @ 8 nB | WF k ? & SC '!dK s GBM ; J t #K 5 *; TPE ! i Q> "b G 9 % IgG ;J @UDR ! TPE Y 2 & 'Q . $ } #/ #~ K a&#9 G7 'lM n .? @ ! ;! .;8 '9# #l Z qT @ /;Q , J .;8 '9# cd+ 3 8;QB 5 "J 'lM "b G 9 'lM & # TPE , #j @ ! a&#9 G7 "b G 9 qV N #B e /;Q n< & - - ^ " . & a&#9 G7 Bn< % #B #; TPE #j ! #; n< & - ^ " . & #; a&#9 6 7 & G7 n< m @ B 7 "J ` # cd+ e ! , Y& & a & 5 ! '! # Z qW ! • 9 &# ^ ;+ & 8 .B & 'a& c#m $ TPE k M 6 7` @UCFR ! &#( - . # ) 0> 20 9 .8# 0 # 4 Y2 0 + I;Q % 8 J#? Y 2 Ae & TPE '! # J % -& ^ t " 89 @ ! 0& *; " Q " k> 6 7 B 8 J#? -+G # ! | CFF # J a CF - & #; W G Ae " Q " TPE J & '9# L + 'Q ' ? ^ + - & - # @ ! ; G+ # Y 2 - + " 7 G # " #$ & vMa € #LM 9 )*+ - @ ! " 6 7 " 7 I2+ G LN n< ,8 l> #B 8 i2 B 8 - Glomerul Basement Membrane
  • 55. # @ ! "J Y 2 # Y X " n .? - 8~ B & TPE # j & J '? #28 Q pUCCR # 5 *; # ^ #? " %b Z '! # J " . 8 n ?x Yx @ Yo e I2+ x 3 5 , 'lM pYx 5 A & 'lM pYo 0 ?I2+ G pX D @' U e•SqHS R ' j A I; / p e ^ K‚ B & 5 a&#9 G7 #l Z ' 5 ! •#? - ; $ - ./ $ 0 #l Z - 8N IB & ;?#/ 0 m a&#9 6 7 & G7 g? - @ ! g I2+ P # TPE k 5 ! '! # Z Z a D 5 ! ^& $ pUCSR B " GH CDE F # 0 TPE 7 $, 8 .8# 0 $ $, 9 0 "# ?B A*,/ Plasma volume Fraction Fraction Removed Removed (%) Remaining (%) 0.5 40 60 1.0 62 38 1.5 78 22 2.0 85 15 2.5 91 9 3.0 94 6 9 - Base natural log
  • 56. #Q & U &Ga` 8 ./ $ R i& 8; & ; ]& % pUCTR B " #l Z a UCTRUi& 8; & ; ]& R 8 #? a&#9 G7 5 a 5 ". > „C 6 7 & G7 n< & - ^ " a&#9 6 7R "b G 9 0 m :7 # f P # @ B 7 0& *; & P # 5 ! 8 n ". TPE Gm + ƒ ; U a&#9 5 ! 8! - ./ $ ` " 89 |W - J 5 *; TPE '! # / ,N pUCVR' + n " 7 " #$ - 'lM ' m C3 & "b 8 # ? p^& / „ 8 J#? Y 2 B ; ? - c#: & '! # v # ! X ;+ nB l; @' TPE # f ' m UALPR *Q? - L J & ^&#;QM IgM G a # pY& / „ & > 0 # - @' d A l; &5 ! 8 n + ? 0 # 'lM @ a&#9 6 7 & G7 n< & - A & a&#9 G7 g? nB ' m UCKR 8 - # & ULDHR b& B 0 ; X 8 pY / „ a&#9 6 7 & G7 n< & - ^ 'M9 ' l; + #; - 'lM @'
  • 57. ' m . MK & 0 8 #L I ; # l & J %N , L pY ,N / „ ^ ! ' 5 ! 8 n ". #; Q " 7 " #$ , J , 'lM @ ;? * # f ‚B #l8 & ' a&#9 6 7 & G7 n< & - ` # Q $, 8 .8# 0 K:# 2 # 3 # O "# )3 +0 PI J 0 KL # M# # # N 0 : ;< - . # + Q= TPE G7 $ ' B- MK cd+ TPE Mm c B L 2J 8 n , J % #B .;8 '9# & a&#9 6 7 & G7 n< & - ^ " . & a&#9 @ ! I, TPE Y 2 3 '! # J 6 7 & G7 n< & - . N ^ & #a a&#9 G7 g? IgM m HW % k? 2; & 5 ! 8 n ". ^ # ;! # " . - # 8 a&#9 @ # B 7 `* # Y# IgM _e ` # nB X TPE & & - - & ' 5 ! #;8 & Q e a&#9 6 7 & G7 n< & IgA 6 7 IgA a&#9 G7 IgA 'lM nB " . B @ ' #+ ' Qa 3 IgA 'lM 2 ; & ! & a&#9 G7 g? 'lM v ! ' a&#9 Z 5 ! Y 2 8 J#? #/ 0 9 nB 5 ! 8 n + TPE Y 2 n &J` $ AQ $ IgA ' v $ ;L - $ @ B < * l; &5 a&#9 6 7 & G7 n< & #B IgA '! # ! ' 5 ! 8 n + @UCCR ! l; ". #; v # a&#9 G7 IgA 'lM nB ^ + - 9 a&#9 6 7 IgG n 2 J @' " Q $ c B IgG #X BI2+ a&#9 G7 IgG $ & U' a&#9 G7 |VW & +R ' + TPE " # & > I : " L!. vM - # 8 '! B 7 #; #j 5 &# e 0 #j & ;7 6 7 a&#9 G7 Z |EF„HW #K I2+ C„CqW & - 5 ! Y2 ^ & @ 8 & > . ^ # .$ nB k # $ 3 `a & & B n .? a&#9 G7 IgG _e & C„S a&#9 6 7 & G7 n< & #K 3 #?J G a " . |VF IgG # _e TPE Y 2 va ; '9 Vs IgG & # TPE # % Y 2 jJ @ ! Y 2 #; # j " . TPE 2 ; pUCTR' 5 ! 5 " S % ! e "J G " . & a&#9 6 7 a&#9 G7
  • 58. G " . & UX R a&#9 6 7 & G7 IgG & # TPE # % Y 2 # j „S UCTRU- R IgG v# #/ 0 # vM & ! Y2 <; # # $ 8 J#? "b 8 # ? @ #K oe '9 Vs„HS #t & ! .;8 IgG # ` # v # '9 Vs , J '? - / & 5 8t;Q 5 9 a - B- MK & " M4 Ga# |EH„HS + ;QBJ '? IB ^&#;QM @UCVR' & # |VV |EW |EW |W- J B vM - ./ $ ` 2 J @'! B 7 ;*B % 3 #? IgG o e <; nB #28 ; , B - 8N # % Y2 - # 8 ' @UCWR' 5 ! 5 " T ! UCWR- Jq- - ./ $ ` TPE Y 2 & G a IgG & - J - u &# " . „T
  • 59. 0 y.$ $ ' TPE Y 2 Q c B IgG nB 2J |DF & + IgG4 & IgG2 IgG1 IQ '9# @ #l ] "J IQ ; 'lM " !# 9 v # - B ' IgG G v 8; 8B G L IgG G @UCE„CDR 3L9 ' Q , J 'Q 8 )*+ % B# Q IgG 1 ! G a ;4 % $& …Q - " 5& Y M FcRn ;4 ! ;4 - #l @USFR' 5 ! 5 @USCR B ^ ; " 5& #!G ;J ! &# ;!dK 0 e 7# @' GL " Q IgG .;8 '9# # K5 nB 8 ' *8 % ? IgG .;8 '9# ! 5 " '?# d Y 2 0 + CF @USS STR 8 K 5 "J ! #; "J .;8 IgG _e ! FcRn ;4 .;8 a L ; b #l B] " # 7 0 e IgG .;8 '9# ' I Q , J IgG &5 5. '9# IgG ^ L & 8 *8 % ? O # IgG .;8 I l8 #l - @USVR' ^ # ' + 8 , J 8 n .? v #K 2 TPE k ;J nB 8 ,8 @ ! B < IgG .;8 Ae & B U & G7 - MK R IVIG & TPE " . B " g IVIG 5 *; " * B " 0 e @' 5 ! ] .K #j ;J ' 5 ! h< # 7 @ ! TPE 0 #j ! ;J e & , &5 ' a FcRn ;4 ^ : ',$ " G7 IgG " 6 7 …8 - MK . ; J 1 #B G ! - 8 ` #Q " G7 IgG IQ 2; nB v , J & #B & ! IVIG &TPE 0 #j P #l - @ ! ' -L & &J - # ` # "b 5 _e TPE @ #K #g B ;J IQ & # ;QBJ #LM 9 1&#! X ;+ IVIG L + ! ^ #; J IQ @USWR #`# {a # ? ( B" 5 *; Y 9 0 m '! $ ;L - 2; @ ! - nB †9 'xa e & B Z & # ,8 TPE % b @ J i Q+ CC L " TPE #t 10 - Rebound
  • 60. ^ ! '! # TPE vM .;8 '9# L8 $ ^ + #B m :< g ; - > 5 9 & n .? TPE , 6&#7 Gm + ' -L 5 - ! 5 B Z B- MK # 2; @ ! .;8 ^ uQ , M & # $ *8 % ? cd+ 8 J#? - 5 ! m TPE 8 J#? Y 2 8 #/ # G 9 " . B " # K M$ G 9 8 B^ M cd+ 8 #/ # ' -L TPE - 8~ B @USSR' B^ M - ' Q+ -;? X 2 ; & , ‡J % ; ' ? n .? Ae & B ;J @USSR B n .? 8 #/ # G 9 ' - MK J - - 8~ B BIgG '! # / IgG '! # @ /;Q U # L . ? 0 m :7 - u &# R - u &# % B- MK '! # " . B- u &# &' 8 n G a 5 ! # ˆ 0X 'M9 I2+ n .? 0& * - ! 5 ! 8 n {: ' -L @UCTR ! 5 ' Q - u &# $& - 8R <, 0 "# += TPE ,) 4 # +KE P ; ? "J Y 2 Gm ? & ! 6 7 TPE M+# #B 2+ | Ts & + & 5 |CFF Q I2+ % ^ 6 7 3 @ /;Q "b Z &# & " . B " ! O a 'M9 a #l Z |SS I2+ CqW 3 @' TPE 8 J#? Y 2 ^ 7 - ./ $ 0 k @ a #l Z | CW I2+ & 3 & Z #; #Q ! #; I2+ N #B B " IB C '! # Q Z#, & 5 ! '! # #; & #; $ ! '! # 5 a n '! $ ;L - @ nB I2+ CqW„S # X BI2+ '9 CqW „S & + I2+ % R &# " " ! X †9 I2+ % U .? 8 J#? Y 2 " ' Q - B I2+ " ! # # T S #B & 5 ^ "b G 9 '! # nB $ @ ! 8 .B n .? . & G > nB 2 ; " n .? i Me ƒ ; & #? #B # 8 < I2+ # # CqW #X BI2+ '! # c e B & #t I2+ n .? ! TPE Y 2 @ 8;QB ' #B I2+ C„CqW 11 - Adjuvant
  • 61. - 8 S D # K:# += 0 , 0 TPE ,) 4 " # b '9# " ^+ " . Gt M 9 Y 2 0& * @ 5 ! 6 7 Z U a&#9 G7 n< #l Z ^ ; R 2 ` & U 2 .;8 R a&#9 G7 n< & & & .;8 '9# 'M9 R & TPE IgG 6 7^t " 8 l; G ; " & U a&#9 6 7 g? . N " . % #K M e & ' Y X , J 0 + )*+ # '9 CS #B TPE B K 8;QB a&#9 6 7 ^ " . U # " 5 J $ R $ IgG & CF H K $ TPE W ! '9 m S C # "J a&#9 G7 @ # " & 8 MK m DF ' -. # +KE ,)= 2 8 TPE $ * T % Y2 $& "J " L TPE Y 2 # AABB M m @' T„W Y 2 & % & S„T #B & #? #B 8 < I2+ # # C„ CqW ^ ƒ ; & L8M ‰ $ 0 ? '! $ ; Y 8 Gt Š 7 B 7# @' # f G a #B Š 7 B / J ,;Q Y2 3 G , ;*B & % TPE A ' -L UGBSR 5 -M K & e B ' TTP Š 7 #/ L @ ! & B & - " & ; ] ! n .? & " 7 LDH _e nB " . B 8 , @ # K Y2 ' ; & T„S ,J ". " & & + #; TPE # X B5 & Y 2 ,; & TTP 9 &# @ X ! 7 ; # B" # jJ ,‹ l; " TPE Y 2 2J B ; J Ae & 0X ;7 U W„CFR & > X # K 0 m 8 #/ # B& 8 @ ! Y 2 ;*B & Ga + # & 0 : TPE #~ KY 8 @'
  • 62. USER 3 #? , c B „CF ^& $ Substance to Treatment Treatment Treatment Endpoint Remove Volume Interval (ml/kg) (in hours) Autoantibodies 40-60 24-48 Four to six treatments Immune 40-60 24-48 Treat for response complexes Paraproteins 40-60 24 Treat for response Cryoproteins 40-60 24-48 Treat for response Toxins 40-60 24-72 Treat for response Thrombotic 40 24 Treat to establish thrombocytopenic remission purpura/ Hemolytic uremic syndrome Immunologic 40-60 24-48 Two to three rebound treatment followed by immunosuppressive medication
  • 63. - ,) #, , * O0 TPE + ) Q / M# # WFF„CFFF a ,8 # - #; - ,J - y ;Q # 0 # TPE #K Š :< @ 8 ' * ' 5 ! 6 7 ; 3 #? % y ;Q # 0 I2+ #; % n 6 7 `a @ ! ; LQ &#4 B `? & 8 u &# 4 B &# #28 X BI2+ ,J . 2 # 88 ' * ,8 @ ! ;a K 0 2+ . 2 &#9 y ;Q # 0 ` # 6&#7 'M9 - 8~ B a&#9 6 7 g? , J ; & ! 5 !6 7 I2+ # # S„T ^ y ;Q # B ^ ; Y 9 & " ' a ^ + - 9 @ #K Y & " Q 4 B &# #28 a ; U|TF„VFR < " 89 - vM #( + ^ + @ ! ,J ? 5 J # 5& 9 @ # K #a 5 *; - J B# B & - ./ $ 0 @ # . ( ^ M> A , & . " vM # ` - @ - ./ $ 0 - # - #; |W - J #28 & 5 ! &#9 G7 a&#9 "&# g? h 7 ` -;? " #$ v & ' % L #4 B ^ # k |W - J " 1( - # K M$ # @UCTR ! { *7 ;a J 5 ! '! # I2+ m SW WF " - ./ $ @ # G | VqW | V - J - @UCW SsR' 5 ! G > " 5 9 5&#K - ]& P&# & ! ' &# & B ' # Y 9 - J ' . - # I, "75 M ;8 Z ! ;7 8! *9 G 9 ' e #! '> 5 & #? - " . ; Y 9 & 7 5&#K K "& " . 2 ' M a 'M9 - J @ ^ ?# - J i Me Bn8 & @ J # 5 *; n 5 J " ! i&ˆ ! v Bn8 & & USDR- #L 5# " ! ^ ? ! Bn8 & 8;QB ` ! ; Q @UTFR 5 ! ] .K "b&# $ BG ; G "J " !i # 7 & ^ M> - #K |W - J v CS @' ACEI 8 B& g #LM 9 - J G7 "J #/ i 9 @' FDA 8 B- u &# # 'xa h 2 #28 - J #L B - 8~ B .;8 & k # &5 8 '> vM ! B ; ? & B- MK @UTCR ! - ./ $ 2 12 - Angiotensin Converting Enzyme Inhibitor
  • 64. I2+ |EF„HF |W- J ^ M> # ' 0 9 ; ]& #( + ^ + @ ! - ./ $ - ^ # 8 B y ;Q # k I2+ A & 5 ! 6 7 ` " 8 "J # & ,8 ' y M - ./ $ 0 #/ L FFP p 8! G ˆ o#! - @ ' >$ - ./ $ TTP ; " Gt Š7 - u &# % 8 ./ $ UG FFP - ./ $ I2+ |EF„HF TTP " @ # M &" ? ; ? u &# ; '? @ B G L - "J & "J # / & #L B ! ;a K 2 # / UH K # / @ ;! ^ B K & 8 ; &# G a & I2+ #t L + UTSR # K 0 m ,; CF„CW ml ". FFP . 2 kg @' 5 ! - ./ $ |W - Jk ; " Gt .# 7 X #e7 •# " B ; ? - … UV @ . # 7 #~ KY 8 - ! . # 7 #e7 •# XI ; ? ! ; " UW ^ + - 9 & XI ; ? Z#; ;Q8 $& Y 9 'M9 # K #a + #$ G 9 '> ' #a & 5 CT - + #$ G a ' FFP FFP . 2 ^ I2+ #K 2 @ #a#B" ; „^ + & # a? Gt R "J 0 ; UFFPR M - . 2 Œ < & Œ G 0 : ' -L U5 ! 'Q 2 Z 88 B &5 8 ! @ & L & ' B ; ? %b . ? # - & "J Q " " FFP . @ ! " 75 M ;8 &# & B ^ ; #e7 "J v Bn8 & 8 ; Q+ Bn8 & n .? ABO #l K B5 &J#? $& 0 #; Y O . 'M9 QM 4 B & 0 #; #K ! Bn8 & n .? & # , " 7 I;Q $ 0 #; - 8~ B & 5 ! 5 #K " 7 & FFP $ e FFP @ ! g9 B€ # & .; †9 ' -L ! " 6 7 @UTTR ! ! y ; ? J Bn8 & &# #28 13 -Volume overload
  • 65. CV ‰ FFP m :< TTP " # a? # I 0& * - ' FFP "J v & . @UTVR & L B @ VIII ; ? & "b 8 # ? & 5 #L - B ; ? Y % b . ? ". pCW$,) 8?A E - @ B nB *9 G 9 ^ ; #e7 "b #l 5 ! ^ ? # 8 G ;8 HIV ,HCV ,HBV 8 8! 4 n! BP&# & 5 &J#? ^ ? # ]& - B19 P&# &&& & HAV Gt 4 n! a ? BP&# & * ; & # & + ' Pooled ^ :> % 5 8 ! „ ^ + @ 8;QB ^ ; G a & 5 - u &# C - u &# Gt R ( B ; ? g #l &' B ; ? "? R VWD " - 8~ B @' N "b 8 & UIII - &# ; J & S @' VWF - /8 B^ L I M 7 & + # 'Q #j U # M & ' 5 # B *9 B ^ ; #e7 nB 0X :> #/ L 2 'Q & B & CCF Ga + 5 88 B @' CE5 88 B 5 ! 'Q 2 *8 ƒ ; Y 9 3 ^& ' B " 7 Gm + Z ! . #? @#K #a @'?#K B 7 #a 5 *; Y& ' 5 88 B & # 5 ! Y 2 &# & B'Q - ./ $ ` < Y " 89 " IB HES # l 9 8: yM B^ M> # ' ; z . B^ L &+& J ' B K A; HES @ # 5 *; v @' B ' # Y 9& "J . @ ! 5 &.? - y M ^ M> 2 X # 9 & #? HES ' Q % b# J Bn8 & &# " "J CH # " a #28 X # 9 - # 5 ! ' '9 SWqW Hetastarch Q " # f & I2+ n .? v & 5 ! #L B 3 "J ,$ G a # f Y• & ;K "b 8 # ? & ' # B - J Y# Y - u &# UPTTR - ; &# Cs # ' #; Pentastarch # 0 m 0 # f - & #? @ ! . ; B @ #;B # 9 14 -Cryopoorprecipitate Plasma 15 -Solvent-detergent Plasma 16 donor retested Plasma 17 HESX L "& 18 HESI L "&
  • 66. " n8 & FFP - J #? - ./ $ ` % " 89 HES ^ + #B 7 0 ; '? Bd 0 ;9 Ae & #? # - 8~ B & ' o#e 8B @ # & 1 8; ^ ! QM 4 B &# I QM UHES & - J - R - ./ $ 0 8 - 8N # & U I2+ C„SR BI2+ 3 #? @ B L 0 #; ' Q a m :< @ ! ^#;8 3 #? QM$ #B I QM ; QM$ ' #;, I QM ^#;8 @ ! 5 *; - ./ $ " 8 ' 0 #; # &+ Y 2 3 #? QM$ G a & & _m & 7 3 '9 8N | TWqE I QM 0 MK Y& O . O # 0 #; ' Q &# e % @ ! CFR |CF I QM 0 MK " &.? G ! 5 ! ,8 BI b @UTWR'? nB | sqE O . # ' &#L O # ;QBJ - ./ $ ` #; % #B - 5 !Oa O . # #; % #B Y#K M SFF Cacl2R I QM #M U ! N#K 88 G > 5 9 • 9 "& QM 4 B " vM @UTE THR 8! U ! CD # K M$ ',$ 5. I QM _e = > O a ^#;8 J # " @ ! QM 4 B 19 - Fulminant hepatic failure
  • 67. HZ TPE I Q / M# # Y * # ?GG A*,/ Replacement Advantages Disadvantages solution Crystalloids Low cost 2-3 volumes required Hypoallergenic Hypo-oncotic No viral risk No coagulation factors No immunoglobulins Albumin Iso-oncotic High cost No contaminating No coagulation factors "inflammatory No immunoglobulins mediators " No viral risk Hydroxyethyl Moderate cost No coagulation factors starch Iso-oncotic Long-term residual No contaminating levels of HES "inflammatory Contraindicated with mediators " renal failure Possible coagulopathy Plasma Maintains normal levels Viral transmission risk of: Citrate load immunoglobulins ABO incompatibility complement risk antithrombin Allergic reaction other proteins Sensitization -. # "# += +0 * # ,X 6 M += 2 # K M$ # 3 #? ^ 7 & - # & - 4B 0 #; 'a ( Z - #;, - # @& L " 6 7 " 7 A7#N / /N G ! 0 l+ # @ # K #a - 4B 0 #; G > => 1 - ./ $ ` I2+ & 1 8 J#? 0 ^ & 1 k a&#9 G7 I2+ n .? G > @' # G " 7 #; " 7 " #$ '9# " . & & #;
  • 68. ' J ; G+ # # 5. I QM ^: O# 0 #; "J ; B'9# 0 #; O . '9# ^ I % @ 8 # K M$ ' ( Z " 89 0 #; 5 #;QK Z *; GM9 L 1( - @ 8 5. ; ! O . TPE 8 J#? RBC " #K ^ 7 # "N - ; @' " % ;Q ( jJ K#B a ? 2 ; & 5 ! 5. ; '9# ! #; ;< 2 #28 " 7 " #$ '9# " - 0 m 0 #; ' m :7 $& Y 9 0 m ' - " 7 " #$ '9# - @ ! i Q> Me #j @ ' >$ ( " 89 - 4B c#: " L #;8 QM 4 B ' -L ! "J " . ; '9# n 0 #; O . '9# #K " B c # R { *7 .; 2 #28 ' -L I QM { *7 nB @ B & dK ' (& - # ! & " 7 ? '? ! K I 9 ' '?# & U , ^ ;Q #a 0 #e7 - #; •# ; " @ ! w vMa I; 0X ;7 " &.? 0 m 5. I QM Y& & O a ^#;8 L 8 M ' (& - 8N @ @' & #B & 0 #; O . '9# nB I QM p' P#; GL! V 0 #; @0 #; I # Z#; Q8 & 0 #; I ACD-B SFACD-A 0 m & ' I 0 #; | T & + ' 5 *; Y#? - #; ACD-A @ ! . 2 CV p C D p C # UWB/ACDR (Z G "7 - ;Q WB/ACD D pC E p C ; j ' Q X ' I 0 #; | S & + ACD-B @ ! ; 0 #; ' Q #e7 " . ;lM 0 #; I # Z#; Q8 & ' 0 #; ( Z |V & + 0 #; I ! O a ACD M> A , # - ^ # 5 *; ' -L & |VEqH ^ @ 8N # 3 #? Xm & &' a DF - 4B # # 9 @ # " . ; 0 #; c 7 # - 4B @ ! " % ;Q ( 0 #j 2 #28 2 ; - J^t # R # - ./ $ ` 3 #? ^ 7 5w 0 m :7 - k , J 8 ./ $ Y 9 & $ B ; ? 6 7 'M9 U HES |W ACD-A v # ,8 - 4B @ ! GL - ./ $ ` 20 - acid-citrate-dextrose
  • 69. jJ 2 # ! 5 *; 0 #; & - 4B # a @ ! 5 *; ACD-B - 8N 2 - # 8 @' ACD #;LN I2+ & #; - 4B #j ( c#: ! ( % ;Q jJ ; 0 #; ' Q &# " . Bv # @ B TPE 8 #? . ` M I2+ " . &5 Ga + ,8 - 4B % ;Q # & ! 5 *; #; "7 # K M$ l8 - 4B + & TWR ! ?( - ^ # WFF "J + & CHWFF TPE 8 J#? B + & WB/ACD ^ M> - B # B 0 m @U - ^ M> #B - 4B @ ! B 7 ?( - ^ # #; - 4B -. # P Q 4 P 0 += TPE ,) 4 [ #l ; ? nB v & #l , c B P # B / J B # # Y# - u &# ?&#;L CBC & # % 3 #? @ ! dK #l I Gm ? #K @ J G B ; ? & B' &#;L #K '! #l I, ;L - @' # O a B / J B # ' 'm#? " '9 8N 0 &#( TPE va ; B / J # / ,;Q Y 2 # / 7 5 /J & 8 # ^ & ;?#K 0 m 0 a&#9 6 7 & a&#9 G7 2$ @U ! B'Q m :< R ! - 8 S D# ] += NE 0 * " < T 0 " & 0 K += TPE TPE L m @ ! Y 2 3 b & ' a # 0 L " 5 J 0 m k ? TPE ? 0 M L!. "7% ! Y2 # % & # "7% & + B' a # 8B Y2 TPE 8 #? ; # G8 # @ ! 5 /; & Ma ; 5 /; Q b & `a #LM 9 Z > GL &# @ 8! 5 I M CPR k #! - B . " ; #;Q " TPE Y 2 # @ ! P#; # ? @' 5w & B' a # + & % + TTP ; " 8 ^+ ! " 0 ! @ # K #a '> ' 3b& % 0 L UICUR @ ! Y X TPE G+ # 8 %!. g+ 8 - " ^+ h:<; %!. & 5 ! Y 2 l8 - B 5 I M ; # k G+ # A M 9 @ ! P#; 5 B TPE A8
  • 70. ! 0 * 0 TPE ^ / # _# ! *# # K UG B& # l A; 7 cd+ #28 <; # cd+ TPE 8N 0 9 B& B Œ & # TPE 0 #j @ ! #j " I ; I2+ & ;! 4 - u &# ^: B& u = > @'Q P#; @ #K #a #j Q TPE k ' a&#9 G7 n< & > #d "L && # 9 A > O # & 'lM # 3 #? #j 3 . 2 G L Œ - # 0 m " 0 > - &' @# L B& g 'lM ' 5 " ;?#K 0 m & > 0 e p 8 9 B& - @'Q G L BŒ # & 5 #L 8N # f ^; 8? % y&#4 & ^ # &# " &. # "&. # - ; Q / -Q / @UTs TDRI ;* & " Q #;* A - 4 ML Œ U- Q # R L MK B% ; J & B0 Q 8 B& g @UTDR Oa #/ & 'Q ea ƒ ; - y 8? @ $& M L -#8 @ n .? , J . 2 3 Mm ? ` ? B& cd+ M e 5 *; 3 "L 0 m ! . 2 % & B& ! . 2 K ! c#: % & n B& & # K #a @ c#: G a Mm ? # Y X BI . J cd+ O # ?#: B& & # TPE #j #/ ;+ IQ L @ ! G & G + # Y X B- u &# cd+ & IQ ; 5 88 & Q B& 2; & #K cd+ 3 #? B #; - SC @ ! " - X 0 #j ' -L - G8Q #l g9„ :9 @UVFR i 8;$ va ; Mm ? B& - . 2 SV . G # X & G # ; Gt U ACEI R - Q w J ^ BI . J 5 88 , B& @UVCRU "J ! " Q 4B&-8 # .2 Y 9 G R ! `ea #?J G a '9 21 - Succinylcholine
  • 71. ! # ` &<# UH B- u &# A; 7 ` # cd+ #28 $ <; # cd+ Ae TPE #l # ? - ./ $ 0 5 *; 0 m @UVS„VVR ! . B ; ? & + nB 3 Mm ? BŽ ; - - J Gt B- u &# ! nB 0 > @ B & | VF„HF " . B ; ? ' ? - @UVWR 5 " SS- ; ;Q ; ? ' ? & X & IX VIII VII V B ; ? PT n .? X nB 5& > ; ' 5# B U ^ ? Q - ; &# " R aPTT& U- &# &# " R Z a $& G #l8 n .? IB U- &# " R TT @ 8 &2 ^ # B ; ?" @UVWR ! & L ( Z " 89 - 4B & ;! nB - #; $& a&#9 G7 n< ,8 X "b 8 # ? Ga |EE "J '9 HS & 3 #? Ga |SW "J @UCVR 3 #? ; ? ' ? & X ,VIII B ; ? 8t; & C„S X B ; ? .$ - # 8 @ #K # + 3 '9 V - ; ;Q B ; ? a ? B^ M> " & 8 % ; B ^ ;7 @ # 5 *; - ./ $ 0 " 89 22 - Ristocetin
  • 72. CDE T # " < $,8 D # # a ?GH A*,/ Hb Percent Decrease Percent Recovery 48 Constituent from Baseline hours after Plasma Exchange Clotting factors 20-25 80-100 Fibrinogen 63 65 Immunoglobulins 63 ~45 Paraproteins 30-60 Variable Liver enzyme 55-60 100 Bilirubin 45 100 C3 63 60-100 Platelets 25-30 75-100 * Replacement fluid consisting of 4 to 5% albumin in 0.9% sodium chloride.
  • 73. nB k ; @' ] #K B' nB A; 7 2; % Z & > - @UVER' 5 ! ] .K |WSqE |DqV # f; e % 3 ; & M Z 88 $ 5 /; 5 ! I2+ " . 0& * ! X ;+ 5 #;QK @' 5 *; 0 l8 #28 Ub * #; &# nB R 8 J#? Y 2 #; '9# & #; BI2+ III - &# ; J .$ B ; ?# 8 B B' @UVER ! B' #; nB ;+ & ;K & ". U ' " . B & +R '9 Vs„DE @UVTR U% ; 4 B % ; J " <; .f ; " 8t; R #K #; "J BI2+ % ; B ^ ;7 0 m G 9 '> Mm ? TPE Y 2 & & e 0 m & 5 ! ^#;8 'a % ; B B#; # K #a Q Y 2 + #$ " BG L - @ ! 5 *; - ./ $ ` < " 89 ' & @ ! # K M$ , J cd+ !. 2 TPE c # 3 " . @ 8! • 9 Ga + -u e B]& B & 3 #? B B]& - - #; ! @' |SqCs # #K #a 3 #? B '> K 88 B - n8 & @UVHR ! 5 " K 88 B |CqW #/ 7 + &Y B 0 9 Bn8 & Q |EqsH @' 5 ! ] .K |VqHW #? B i Me Bn8 & " . - #; U # K #a 8 J#? '> B' Q |VqSs & ^& # U|CqER 3 #? -+ 7 B5 &J#? ^ ; ' Q n8 & ! i Me Bn8 & @UVsR' 5 p 8 9• 9# & K # } U|FqWR ^ K && & Bn8 & U|CR " Q 4 B U|CqSR 0 #; Bn8 & # & U|FqSR 1#m ; U|FqTR Q*8 P#;Q U|FqVR U|FqWR O# @UVsRU|FqSR 8 J#? ! ' -L B & TPE " #$ ( 9 & i Me Bn8 & Ma M JR 8 B U- ./ $ ` ( Z R 5 ! Y2 ? Z 8B " 7 ? Z 8 .? B& R ' $ L " U" B 3 Q4
  • 74. &5 ! # B ; ? %Q = > 'a TPE 1&#! n @ ! U% "7 @ ! ;< • 9 &# ^ ;+ " Ga + # a o# ! # & >) #* UG & #K ` #j GL! # @' 3 #? Mm ( Z 0 #; IB 0 #; @ ! # d 'K# K &5 7# B G 9" - 4B c 7# I & FFP IB & ! . 2 " 6 7 BI;Q # "X K ;J " 8 @ $& ! 5 *; ' -L - ./ $ ` " 8 # @ 88 iJ ^ M> I QM 0 #; & 5 ! J I QM B" 0 #; B" P#; I QM " & ;? nB J I QM # _e ^ I QM _e c 7# 2 ; ACD-A ^ M> WFF # O . @ # K #a J # l % b Bn8 & nB v #; # ^ M CW„SV #? B 5 /; 0 #; " . "7 U # Y X ". 8 R #; # ^ M FqS„ FqT #; I QM " " . I QM " nB v ^ M> I2+ - O . @UVD WFR #K I;Q $ ^ 7 M "&# ` G 0 #; " ! O a "J 'M9 & #K ! 0 +# f + M 0 #; ` # " . ; & 5 88 B " 3 #? 5 /; " 7 'K id$ n .? & ;ML # 7ˆ I QM J n .? ;? ^ : I QM J & 0 g9 & " 5. I QM nB ^ y&# " B _!# Ae M k I QM @UWF WCR B + 5. I QM nB v ' -L 0 #; O . # $ BIQ L I M9 + :9 B # d % #> 5. I QM nB #j @ #K ! ' 9 N Iy 9 &# # # d % #> ; J @UWFR B & < 7" . n .? •Y# PH @ ! "J nB '9# & 5. I QM OMe 5 8B " QM 4 B 8 #j # d % #> ; J # I & I ; •I . 8 " . B nB • B-LQ g+ @UWSR dK g9 0 #+ 2 K# ] # B ,; .; e > .; pG ! "J { *7 B ' -L I 9 - 5. I QM #; nB @' • #*; & 1 , & ] # # & ECG QT AMm ? " ! G ? I 9 # 5& 9 @ &# 1#m & ; ‚ I 4 - # 8 @UWFR' 5 #K ] .K . 5 8 B ; J&5 !5 • " # .
  • 75. I 9 &# n YX L!. 0 7 Y2 # { *7 I 9 Y /8B & h < @' &#( # ! Gt R M ; " % ; L J 2 0 #; • 9 #/ L `? ' & > & 0 #; IQ ; ^ 0 8 #L 2 ! ' U ; J GBM ; J @ ! A M k "J ! L J G ! 8B #a # j '> 0 #; n8 & &# " . M 9 2 n8 & ACD-B n ACD-AR ( ^ M> 1 UWFR" ; &#4 B - 8NIB @ 8! UWFR . 0 #; " . & ( ^ M> O . '9# UWTRU 8 0 #; O . #; '9# ! ' #; i& 8; " #$ 3 #? 0 #; n8 & @' ; " #$ Q c#‹ A M< Y /8B '9# nB G ! " @' " J ; Q 0 #; n8 & " `a h < 0 m " . ; & O a# l8 ? " 2 # " 5 a .$ 2 O . . 0 #; " . nB # U0 #; G " 7R WB/ACD ' Q n .? 0 #; # & I QM . 2 ' , & I QM B ; J GL! 7 I QM . 2 I M9 I 9 '?# N 88 5 *; 7 I QM 8 I QM #M 0 : ' -L & Y#? I QM @UWFR ! ! & B" 0 m & U| T„|E HES |W - J #; #B Y#K M SFFR ! ? ( - ./ $ ` Ga + " . 5 ! O a Y#K M SFFR & G7 0 : - ./ $ ` " 8 FFP 5 *; % " - 8NIB @UWVR ! O . a S n &I Q '9# USF mg/ml a CW„TF 0 J 3 a CW |CF I QM #M CFcc ^ 4 J #L G a 2 ^ '9 % n TPE Y 2 " m I QM O . @ # O . a CF„CW ' & G7 0 : #; M CF I QM 0 MK ^ Œ @' # #e7 | CF #M I QM ' Q | CF 0 MK I QM #l 0 m #B @ ! O . "N ! 5 *; I2+ k? ! 5 *; | CF #M I QM L m & ! ". @UWWR ! ## 0 MK I QM ' Q "J I QM B" " . Q ?&# 0 m I QM 0 MK . 2 ' - 3 #? J G a , J 5. I QM v # ! ? ( FFP ;Q I QM # " # 7 @UWER ! *
  • 76. # ! 5 *; - ./ $ " 8 FFP B]& @ ! B ; ?" !^ ? ST @UWE WHR ! Y 2 #/ & I QM O . 8 , M &J` $ B5 &J#? 5 *; 0 m m :7 & U B R 3 #? vM B" - @ 8 0 &#( 0 X B3 #? & - ./ $ ` " 89 !, d & 4 T& 4 T 1 J4 P>) #*UH &G ' B^ M _e $ IgE ^ L c B "b ; J Bn8 & - &# # D4- # L C4- # L - ;Q B # l ; & & J #28 & 5 ! G:; G ?& O# " K KI 9 2 v 5 ! J @ ! ' Z 88 ^ ? ; ? & D2- K ; &# BG ?& & BG ' " ! ^ ? @ #K &#9 1 Q & # d ˆ * n .? c m AMg9 • & "b ; J G ; Bn8 & Ae & C5a & C3a # l " M4 O; B ; ? k , Q ?J1 #, & { Bn8 & - @ B & . BIQ L # & IgG /;7&#? # # , ] 7 p 8 9 Bn8 & - I 9 & B @ # K # 0 + Z 88 & • #*; 1 , [ ! " Q 4 B ;> B 5 Q a? B5 Q Y wJ @^ , c#: 88 &# % ; ? J Bn8 & 0 : !'+ % b# J Bn8 & ‘ - J & HES U # I FFPR B5 &J#? # l - ./ $ 0 @ 8;QB ! " # # # , &# B5 &J#? c#: % b# J n8 & - # ` ! "J 'M9 - # ` ! & ' I Q Q ? J1 !@ B & O . |C„T @' IgA ( B ;J & IgA a ? #? IgA & + O . k " M4 J 9#? # Q " ! ^ ? HES c#: % b# J Bn8 & IQ L B 2 ; & C5a & C3a v ' U N&I L " & NR HES . & { *7 # , Bn8 & G ! Bn8 & - @UWsR ! BG ?& & BG ' B5 &J#? HES Bn8 & " . @ 8;QB Q*8 & Ma 'Q Y• ! Bn8 & U% ; ? JR ! Bn8 & " . & 5 |FqFsW ' 5 ! 5 *; , J - ./ $ ` " 89 23 - Stem cell
  • 77. L " & & UWDR SVX L " & HES •Y#? & #B ,8 & - @UWDR' 5 |FqFFE @' 5 ! 5 UEFR SW- y Bn8 & - 8N " K 88 B Bn8 & - 8N &# # / # UPremedication) n { *7 Bn8 & ; " & 5 ! `8 B 8;! @ ! 5 *; - ;Q B ; J ! N ! { *7 Bn8 & - ;Q B ; J n I # M9 U- B-* R - ;Q B B'Q K ; J Gt B- ;Q B ; J n # 5& 9 # IB - ;Q B ; J Y& O . & U- ; - Q & BR - ;Q B Z # K Z 88 [ M @ ! 5 *; Bn8 & - 8N &# # K M$ & - J Gt IgA a ? - ./ $ 0 IgA ! ! Bn8 & ; " t - ./ $ ` " 89 5 *; 0 m @ 88 5 *; - @ 5 *; IgA a ? B5 &J#? TTP ; " B 3 #? @ /;Q , J 0 ! % ; ? J & % b# J Bn8 & " @ ! " - ;Q B ; J # , # l 5 Bn8 & @ ! {a ; #? n8 & 2 0 m . 2 3 " n8 & &# 'M9 &# `ea 0 m 3 #? n B # & '?#K # 8 J#? - ;Q B ; J @ # 5 *; - ;Q B ; J B 5 7 3 #? & 8;QB 0 + Z 88 , % ; ? J Bn8 & FqT„ FqW M$ # O . @ ! ;! / - 5 *; & 5 @ #K `ea ? * • < #? Œ T a SF„TF #B Œ #L UC mg/kgR - #* #; M . 2 I 4 L &# `? # @ ! m #; M FqSW •^ E„CS B ~ @' @ ! 5 *; " " & Y#K M #B Y#K M E " . -M?8 J @#K0 m '9 " " & Y#K M #B Y#K M FqW„C O . Œ - 3 5 *; I2+ Z 8B n .? " 89 0 ; X #/8 - ^ # " " Q 4 B `? # @& Q*8 P#;Q , ',$ "w Q @ # a W„CF #B Œ #L & - #* Y#K M FqW a&#9 G7 O . # ! Bn8 & B ‰ I2+ B 5 8 .? Q 4B" # . - & @ # K Y2 % 24 - Hetastarch 25 - Pentastarch
  • 78. @ 0 &#( ' -L ^u #& " ; & ! ;! / B 5 @ #K . 2 @UEC ESR #K . 2 a&#9 G7 CFF mg " &. # G ; L 3 #? 5 /; B " # G #; # Q -M K ' Q % b# J n8 & 3 #? '> - 8N a K 88 B 9 n8 & - @' 5 ! 5 & @ B ’ ;?#K #a B- u &# L; B $ Q -M 3 #? ! : 8 G 9 -; B " 89 Q -M & G + ^ L " 89 B- u &# @ ^: #, Bn8 & - @' Q -M M9# IgE ;J 8 ‰ # - A2 ; " Q 4 B & , Y 37 37 G ! % ; ? J n8 & IN A & Y & /;7&#? # @ ! 5 #; 3 #? B5 /; m7 1 # n8 & - @UETR' # f; SE @' * Bn8 & - 8N 1 a& # K M$ B 5 J M+# & 5 *; SH - Q w J ^ I . J B5 88 , 5 *; #j y ; ? J n8 & nB •" Q 4 B • /;7&#? # G ! "J Iy 9 @' 5 ! 5 #K #a 3 #? '> '> Bn8 & - @UWFR ! Q*8 0X ;7 & vMa " #( B" ; " & UEW EER 0 * " #;Q B" ; 5 *; LDL 3 #?J •UEVR @' 5 ! 5 • # K #a UEVR A M ? ; - u &# %; P #j @ B ’ - 8 I;Q " ! ^ ? #j n8 & - '+ @ ! -8 # ' *8 L #;L 3 #? 5 /; SD Ss 5# , BI . J - G 9 ACEI @ ! ^ ?# & 8 8 k '9#Q - 8 # @UWFR ! ? Iy 9 ,‹ & - 8 # ` 2 v & I # ` # O . 'M9 - ./ $ ` " 89 - J 5 *; 0 m - 8NIB ' $ - J UXII B ; ? ' ; % R - #L 5# Z 88 ^ ? IQ ; , G & ! ^ ? ' ; & & ;4 % -8 # 0 : - #L 5# % ; ? J n8 & I 9 &# #28 & 5 & -8 # ` 2 ACEI k - 8 # B ACEI 7# @ ! `ea G a '9 SV„Vs ACEI " @ #K 26 - Priming 27 - ACEI 28 - Kininase, ,II 29 - Angiotensin Converting Enzyme Inhibators
  • 79. #/ B5 88 , & 5 ! `ea # X 0 & ;! # X # 9 $ @ !G #5 # 9 ;? O '9 SV„Vs # TPE Y 2 ' K k #! #K n8 & - &# " . - ./ $ ` " 89 HES # l y M ^ M> % 5 *; @ BL !" ] e P UV S " Q 4B@ !5 ' -L IB & B 3 #? IB " Q 4 B @ B ’ IQ L Q I2+ $& #j a&#9 G7 I2+ nB ! " Q 4 B p^& IQ L •vMa " #( '9# a&#9 ;Q I2+ nB " # $ # % 4 5 /; @ ! 6 7 I2+ nB 'M9 " Q 4 B @UWFR B n .? Ma 5 "&# 2 ; & vMa • 0 a I2+ " . " 7 % B ; O # @'Q ` ! " 8N 3 #? a&#9 G7 Y#K M #B “ CFqW & " & & #? ; k #! $ " 6 7" 7 8 B N " g 3 #? @UEHR &2 " " & %b & " ^t # @ ! " Q 4 B &# ^ ;+ n .? v 8;QB " 6 7 " 7 I2+ - & - @ B ’ #`# & 4 B #j " Q 4 B " #$ , J t 3 #? B5 /; g - 8N IB @'?#K #l k #! 5 /; 1 2 ; @ 8 6 7" "7 #; I2+ 88 i& 8; @ #K i <; k #! $ ^ K && & n8 & @ ! ^ K && & n8 & ! " Q 4 B &# Y& IQ L #28 & ;? n .? ' % 4 #LM 9 G e % 4 #LM 9 @UWFR ! " Q 4 B #28 Q - @ #K a&#9 " nB & vMa " #( '9# nB "8 ,$ & B ' - & #; " & #; - pG a B ; ? $& 0 m @UEsR n .? ^ K && & n8 & &# ^ ;+ # / 7 `ea ;a 8 J#? & #B @' ; Q ^ K && & & % & 4 B Bn8 & " 0 'K " . n .? & a&#9 G7 0 #; O . % & 4 B Bn8 & @ ! TF # " #a - ^ K && & Bn8 & @ #K# _e " 7 ? 30 - Trendelenburg's position
  • 80. 5 *; Y J B% 8; & vMa 0 a " " #K & # P#4 @UWFR ! ! 9* 3 P & # 8 c # 3 UW " N ( 9 &# @' . # &#9 B#; #; v # e > &#9 B#; • 9 B ^ ; Q? dissecting BY B & " ?# &# :9 v J ' *9 B & 5 *; " L ' 5# & > . # B#; # &„ #! @ ! $ e> ' O # & I;Q B && ! & ' 3 #? • 9 B J & L 8 8 3 @ ! a&#9 #; G> G & $ ! " #! & ' -e B & & & 8;QB B J B :< " Q 4B 'M9 @UEDR ! " #! • & ' -e $&#7 # Q Q #28 # - @ ! B $& 8;QB B#/Q+ $ & 3 #? " G & ' - ( 9" 0 9" B J &# 0 m @ 8 {a ; 3 #? & a&#9 6 7 -e Ma B " ;? Y v €N M, & z# 8 # ' (& " #a ' , ' -e $&#7 ' (& - # 8 @ ! &#9 $&#7 # Q B" & &' @ ! G+ " 7 < 7 B " '!dK @ ! % Q) Uf # Y @ B & a&#9 G7 0 I2+ #K ! # Y 'M9 3* /8 ". ! 5 #K 2 7 .$ #K & ! 5 „ Ma 'M9 5 - ; ! & J #28 8 K ;J ? @ B & 5 /; k ( Z I2+ ^#;8 5 88 '? FFP I 4 L &# 5 # B % b# J Bn8 & B + K ! ' -L m AQ*a & 3* /8 " 7 ? '? @ ! @ ! B " # G #; 5 ! ;?#K L Q -M ' Q+ & " M4 Ae & I 9 & n8 & 0 ! $ % b# J Bn8 & & ' Q+ ! 3* /8 " # @ ! 5 *; y&#; L - #* B- ;Q B ; J ' -L
  • 81. ! J e P Ub |SW nB #28 "J a# #j G - ./ $ ` " 89 - J 5 *; 8 "J va 9 &# ^ ;+ & ( 9 - @ ! 3 #? Y2 3 I ; 'lM #; #B I ; #; "X & M V $& " 8 ^ :+ 4B ;Q & ; J @ Ga + - J !FFP7 * * P 0 A & # UZ FFP + & CF„CW FFP U' ` #; T # R I2+ % ,$ *9 B P " Ga + # @ 5 88 B - B Z 88 B % I 2+ FFP + & % FFP + & - 8N - O # ; " K 88 B " 89 ;? L B5 &J#? O # &# & B ^ ; @ Ga + #*8 @ ! 0 " - # & z# GM9 L " #$ - ./ $ ` ! &J U5 !" #t &' 5 & " #$ ; N#K ' $ ;Q & ;Q ; " . @' 5 8 J#? ! &5 ^+ TTP ; " |CF„SF ^ t # @ # K #a '> ' .B C 5 ! 5 - < ; ". M e @ # 8B 7 0 ? # / #a TPE '> TPE '> 8 ' (& Z 88 3L 8 #; 5 ! Y 2 TPE .B 5 #B T @ ! A &# %Q 5 8B " L8 5 Ma ; J @' 5 Q*8 Ma ” + &# B] .K # & z# 'M9 - #; 5 !0 ?" @' 5 ! 5 FFP " K 88 '? 5w & 5 Ma GL - # ` ! # n Ma # Y & ARDS Q*8 + P#;Q Y 8 Q*8 G Q G X • 9 Q ? J@ 5 # &# FFP " K 88 '? IB ,8 5 ! ] .K @ #; 1 ! 8! ; #/ GM9 &# & ' *9 a&#9
  • 82. bG g 4 " * TPE c # 3 P+ * C 3 ?GV A*,/ Signs and Symptoms Possible Suggested Treatment(s) Cause(s) Bradycardia, hypotension, Vasovagal reaction, Put patient in Trendelenbug 's position diaphoresis, pallor, anxiety, full or elevate feet, administer saline nausea, blader, bolus, offer bedpan; fan patient, feeling of doom or unknown cause simulate patient (ie, have patient move extremities as much as possible), administer ammonia spirit, aromatic ( be sure to protect patient 's eyes ) Tingling in fingertips or toe, Hyperventilation, Have patient breathe in paper bag, offer flushing, diaphoresis, anxiety fan, encourage very slow deep hypotension/hypertension, breathing . If patient is hypotensive, tachycardia, seizures place patient in Trendelenburg's position and administer saline bolus. Tachycardia, hypotension, Antihypertensive Hold antihypertensive Rx before next diaphoresis Rx: procedure. Administer saline Beta blockers bolus, put patient in Ca channel Trendelenburg's position, increase blockers fluid balance, review type and Hypovolemia volume of replacement fluids, increase % of colloid if using crystalloid replacement. Circumoral paresthesias that Citrate toxicity, Decrease whole blood flow rate, , may progress over entire hypocalcemia increase WB:ACD ratio, switch to body , chest tightness, nau- ACD/heparin anticoagulation, slow sea, vomiting, flatus, diar- FFP infusion rate, administer cal- rhea, hypotension, pro- cium PO or IV(slow push or drip), longed QT interval, tetany add calcium to replacement fluid (continuous flow procedures only & not FFP or Cryo poor plasma) (continued)
  • 83. Signs and Symptoms Possible Suggested Treatment(s) Cause(s) Hives, urticaria, wheezing, Allergic reaction Administer Benadryl IVP, epinephrine facial edema, SOB, hypoten- sub q, and/or solumedrol IV sion, tachycardia Back pain, hematuria, Acute transfusion Discontinue blood component and order tachycardia, hypotension, reaction transfusion reaction work-up hemolysis,SOB Burning eyes, periorbital Ethylene oxide Discontinue procedure, perform setup Edema allergic with double prime, use oldest tubing kits reaction Flushing, hypotension ACE inhibitor change albumin lot number, switch to reaction FFP or colloid starch replacement, hold or discontinue ACE inhibitor, delay therapeutic apheresis for 24-48 hours after ACE inhibitor administration The procedure should be paused when a reaction occurs and the physician should be notified. All medical interventions should be prescribed by a physician. The physician will determine if the procedure should be restarted or aborted. SOB = shortness of breath; WB = whole blood; ACD = acid citrate dextrose; FFP = fresh frozen plasma; ACE = angiotensin-converting enzyme
  • 84. !h0 ) 1 Powel L. Intense plasmapheresis in the pregnant Rh sensitized woman. Am J Obstet Gynecol. 1968, 101: 153 2 Bowman JM, Peddle LJ, Anderson C. Plasmapheresis in sever Rh iso- immunization. Vox Sanguinis. 1968, 15: 272 3 Clarke CA, Elson CJ, Bradley J, et al. Intensive plasmapheresis as a therapeutic measure in Rhesus-immunized woman. Lancet. 1970, 2: 793 4 Verrier Jones J, Cumming RH, Bucknal RC, et al. Plasmapheresis in the management of acute systemic lupus erythmatosus. Lancet. 1976, 1: 709 5 Verrier Jones J, Cumming RH, Bacon PA, et al. Evidence for a therapeutic effect of plasmapheresis in patient with systemic lupus erythematosus. Q J Med. 1979, 448: 555 6. McLeod BC. Therapeutic plasma exchange. In Hillyer CD, Silberstein L, Ness PM, Anderson KC, Roushk S (eds). Blood banking & transfusion medicine. Basic principles & practice. 1st ed. Churchil Livingstone, 2003:519-543. 7. Rock GA, Shumak KH, Buskard NA, et al. Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic purpura. N Engl J Med 1991; 325:393. 8. Mc Collough LJ. Transfusion medicine. In: Handin RI, Lux SE, Stossel TP. Blood. Principles and practice of hematology. 2nd ed.Lippincot Williams & Wilkins, 2003:2060. 9 Cohen S, Freeman T. Metabolic heterogeneity of human immunoglobulin. Biochem J. 1960 10. Lockwood CM, Worlledge S, Nicholas A, et al. Reversal of impaired splenic function in patients with nephritis or vasculitis (or both) by plasma exchange. N Engl J Med 1979; 300:524.
  • 85. 11. Derksen RH, Schurman HJ, Gemelig Meyling FH, et al. Rebound & overshoot after plasma exchange in humans. J.Lab.Clin.Med. 1984, 104: 35. 12. Gilcher RO. Apheresis: Principles and thechnology of hemapheresis. In Simon TL, Dzick WH, Snyder EL, et al. (eds). Rossi's Principles of Transfusion Medicine. 3rd ed. Lippincott Wiliams & Wilkins, 2002:649-657. 13. Chopek M, Mc Cullough J. Protein & biochemical changes during plasma exchange, in Berkman Em, Ulmas J eds.Therapeutic hemapheresis- a technical workshop. Washington DC. AABB, 1980:13-52. 14. Orlin JB, Berkman EM. Partial plasma exchange using albumin replacement: Removal & recovery of normal plasma constitutes. Blood. 1980, 56: 1055. 15. Mcleod Bc, Sassetti RJ, Stefoski D, Davis FA. Partial plasma protein replacement in therapeutic plasma exchange. J. clin. Apheresis. 1983, 1: 115. 16. Waldmann TA, Strober W. Metabolism of Immunoglobulins. Prog Allergy. 1969, 13: 1. 17. Strober W, Wochner RD, Barlow MH, et al. Immunoglobulin metabolism in ataxia telangectasia. J. clin. Invest. 1968, 47: 1905. 18. Wells JV, Fundenberg HH. Metabolism of radio-iodinated IgG in patients with abnormal serum IgG levels. Hypergammaglobulinemia. Clin Exp Immunol. 1971, 9: 761. 19. Wells JV, Fundenberg HH. Metabolism of radio-iodinated IgG in patients with abnormal serum IgG levels. Hypogammaglobulinemia. Clin Exp Immunol. 1971, 9: 775. 20. Brambell FWR, Hemmings WA, Morris IG. A theoretical model of - globulin catabolism. Nature 1964;203:1352. 21. Junghans RP, Anderson CL. The protection receptor for IgG catabolism is the 2-microglobulin-containing neonatal intestinal transport receptor. Proc Natl Acad Sci USA. 1996, 93: 5512-5516.
  • 86. 22. Dau PC. Immunologic rebound. J. clin. Apheresis. 1995, 10: 210-217. 23. Derksen RH, Schurman HJ, Meyling Fh, et al. The efficacy of plasma exchange in the removal of plasma components. J.Lab.Clin.Med. 1984, 104: 346. 24. Junghans RP. IgG biosynthesis. No " Immunoregulatory feedback ". Blood. 1997, 90: 3815-3818. 25. Yu Z, Lennon VA. Mechanism of intravenous immunoglobulin therapy in antibody-mediated autoimmune disease. N Eng J Med. 1999, 340: 227-228. 26. Weinstein R. Basic Principles of Therapeutic Blood Exchange in: Mcleod BC, Price TH, Weinstein R, eds. Aheresis: principles & practice. 2nd ed.Bethesda, MD: AABB, 2003:295-319. 27. Brecher ME. Technical Manual. 15th ed.Bethesda. AABB press, 2005:139-161. 28. Lewis EJ, Hunsicker LG, Lan SP, et al. A controlled trial of plasmapheresis therapy in severe lupus nephritis. N Eng J Med. 1992, 326: 1371 29. Alving BM, Hojima Y, Pissano JJ, et al. Hypotension associated with prekalikrein activator( hagemen factor fragmnent ) in plasma protein fraction. N Eng J Med. 1978, 299: 66. 30. Pool M, Mcleod BC. Pyrogen reactions to human serum albumin during plasma exchange. J. clin. Apheresis. 1995, 10: 81. 31. Weinstein R. Principles of blood exchange in: Mcleod BC, Price MJ, et al. Aheresis: principles & practice. Bethesda, MD: AABB, 1997:263-286. 32. Winters JL, Pineda AA. Hemapheresis. In Henry JB(ed): Clinical Diagnosis & Management by laboratory Methods. 20th ed. WB Saunders, 2001:776-805. 33. Mcleod Bc, Price Th, Owen H, et al. Frequency of immediate adverse effects associated with apheresis donation. Transfusion. 1999, 39: 282-288. 34. Owens MR, Sweeney Jd, Tahhan RH, et al. Influence of type of exchange fluid on survival in therapeutic apheresis for TTP. J. clin. Apheresis. 1995, 10: 178-182. 35. Weinstein R. Prevention of citrate reactions during therapeutic plasma exchange
  • 87. by constant infusion of calcium gluconate with the return fluid. J. clin. Apheresis. 1996, 11: 204-210. 36. Pierce LR, Gaines A, Finlayson JS, et al. Hemolysis & acute renal failure due to the administrations of albumin diluted in sterile water [ letter ]. Transfusion. 1999, 39: 110-111. 37. Kovithavongs T. Calcium administration during plasma exchange for HUS/TTP. Canadian apherersis group bulletin. June 1999, 2-3. 38. Stigelman WH, Henry DH, Talbert RL, Townsend RJ. Remove of prednisone & prednisolone by plasma exchange. Clin. Pharmacy. 1984, 3: 402-407. 39. Pramodini B K-B, Woo MW. A reveiw of the effects of plasmapheresis on drug clearance. 1997, 17: 684-695. 40. Wood GJ, Hall GM. Plasmapheresis and plasma cholinesterase. Br. J. Anaesth. 1978, 50: 945. 41. Perseghin P, Capra M, Baldini V, Sciorelli G. Bradykinin production during donor plasmapheresis procedures. Vox Sanguinis. 2001, 81: 24. 42. Owen HG, Brecher ME. Partial colloid replacement for therapeutic plasma exchange. J. clin. Apheresis. 1997, 12: 87-92. 43. Sultan Y, Bussel A, Maisonneuve P, et al. Potential danger of thrombosis after plasma exchange in the treatment of patients with immune disease. Transfusion. 1979, 19: 558-593. 44. Domen RE, Kennedy MS, Jones LL, Senhauser DA. Hemostatic imbalances produced by plasma exchange. Transfusion. 1984, 24: 336-338. 45. Flaum MA, Cuneo RA, Appelbaum FR, et al. The hemostatic imbalance of plasma exchange transfusion. Blood. 1997, 54: 694. 46. Owen HG, Koo A, Mc Ateer M, Brecher ME. Evaluation of platelet loss during TPE on the COBE SPECTERA. J. clin. Apheresis. 1997, 12: 28. 47. McLeod BC, Price TH, Owen H, et al. Frequency of immediate adverse effects
  • 88. associated with apheresis donation. Transfusion. 1998, 38: 938. 48. Mcleod Bc, Sniecinski I, Ciavarella D, et al. Frequency of immediate adverse effects associated with therapeutic apheresis. Transfusion. 1999, 38: 282. 49. Strauss RG, Mcleod BC. Complications of therapeutic apheresis. in popovskyma, ed. Transfusions reactions. 2nd ed. Bethesda,MD: AABB press. 2001, 315-38. 50. Strauss RG. Mechanisms of adverse effects during hemaheresis. J. clin. Apheresis. 1996, 11: 160. 51. Silberstein LE, Naryshkin S, Haddad JJ, Strauss Jf. Calcium hemostasis during therapeutic plasma exchange. Transfusion. 1986, 26: 151. 52. Crookston KP, Simon TL. Physiology of apheresis. in: Mcleod BC, Price MJ, et al. Aheresis: principles & practice.2nd ed, Bethesda., MD: AABB press. 2003, 71- 93. 53. Szymanski IO. Ionized calcium during plateletpheresis. Transfusion. 1978, 18: 701. 54. Hillyer CD, Silberstein LE, Ness PM, Anderson KC. Blood banking & transfusion medicine.Basic principles and practice. 1st ed. Churchill Livingstone, 2003:509-518. 55. Hester JP, Ayyar R. Anticoagulant & electrolytes. J. clin. Apheresis. 1984, 2: 41-51. 56. Bolan CD, Cecco SA, Welsey RA, et al. Controlled study of citrate effects and response to IV calcium administration during allogenic peripheral blood progenitor cell donation. Transfusion. 2002, 42: 935-946. 57. Korach JM, Berger P, Giraud C. Role of replacement fluids in the immediate complications of plasma exchange. Intensive Care Med. 1998, 24: 452-458. 58. Dutcher JP, Aisner J, Hogge DE, Schiffer CA. Donor reaction to hydroxyethyl starch during granulocytapheresis. Transfusion. 1984, 24: 66.
  • 89. 59. Ring J, Messmer K. Incidence & severity of anaphylactoid reactions to colloid volume substitutes. Lancet. 1977, 1: 466. 60. Kannan S, Milligan KR. Moderately sever anaphylactoid reaction to pentastarch (200/0.5) in a patient with acute sever asthma. Intensive Care Med. 1999, 25: 220. 61. Jones HG, Bandarenko N. Management of therapeutic apheresis patient. In Mcleod BC, Price TH, Weinstein R, eds. Apheresis: Principles & practice. 2nd ed.Bethesda,MD: AABB press. 2003:253-282. 62. Mcleod Bc. Therapeutic apheresis: A physicians Handbook. 1st ed.Bethesda. AABB press. 2005:27. 63. Leitman SF, Boltansky IT, Alter HJ, et al. Allergic reactions in healthy plateletpheresis donor caused by sensitization to ethylene oxide gas. N Eng J Med. 1986, 315: 1192-1196. 64. Owen HG, Brecher ME. Atypical reactions associated with use of ACEI & apheresis. Transfusion. 1994, 34: 381. 65. Aghishi T. Anion-blood contact reaction (ABC reaction) in patients treated by LDL apheresis with dextran sulfate-cellulose column while recieving ACE inhibators. JAMA. 1994, 271: 195. 66. Olbricht CJ, Schaumann D, Fischer D. Anaphylactoid reactions, LDL apheresis with dextran sulfate & ACE inhibators. Lancet. 1993, 341: 60-61. 67. Standards committee of the American Association of Blood Banks: in marianne A.S(ed): Standards for Blood Banks & Transfusion services. 23rd ed.Bethesda MD, AABB, 2004. 68. Newman BH. Donor reactions & injuries from whole blood donation. Transfus Med Rev. 1997, 11: 64. 69. Montacer-kuhsari J, Voller H, Keller F. Pulmonary air embolism. Intensive Care Med. 1994, 20: 166.
  • 90. TPE
  • 91. TPE TPE ! " TPE %, ) / TPE . - +, % (AABB & 'ASFA , )& * & %# $ 5 '%( 3 ), 4 '2 0&,1 <3 & : ;-. "4 %0&,1 6 7 8 9- 53 . - = 0& !$ 0 >? @ ? & , TPE < I )& * D 1& ) . + B& !$ C TPE A ,. " <II )& * 5 & 3 E F $ & GH & 8? -I . - = TPE 4 ,. " <III )& * 5," ,- ) N ) = $4 C TPE 3 =+ 53J- KLM % J 3>J 53 ) O * . ,? A TPE )," 0 . <IV )& * 1 - American society for apheresis 2 - American Association of Blood Banks 3 - Adjuvant therapy
  • 92. ) '(&# $% "! Disease Procedure Indication category Neurologic disorders Chronic inflammatory demyelinating Plasma exchange I Polyradiculoneuropathy(CIDP) Acute inflammatory demyelinating Plasma exchange I Polyradiculoneuropathy(AIDP or Guillian-Barre syndrome ) Myasthenia gravis Plasma exchange I Lambert-Eaton myasthenic syndrome Plasma exchange II Multiple sclerosis and related disorders Plasma exchange Acute fulminant central nervous system III demyelination Relapsing or progressive III Paraneoplastic Neurologic syndrome Plasma exchange III Immunoadsorption III Paraproteinemic polyneuropathies Demyelinating polyneuropathy Plasma exchange I IgG/IgA Immunoadsorption III Polyneuropathy with IgM Plasma exchange II (±Waldenström's macroglobulinemia) Immunoadsorption III Cryoglobulinemia with polyneuropathy Plasma exchange II Multiple myeloma with polyneuropathy Plasma exchange III POEMS syndrome Plasma exchange III Systemic (AL) amyloidosis Plasma exchange IV Inflammatory myopathies Plasma exchange III Polymyositis or dermatomyositis Leukapheresis IV Inclusion-body myositis Plasma exchange III Leukapheresis IV Plasma exchange III Rasmussen encephalitis Plasma exchange III Stiff-person syndrome Plasma exchange III (continued)
  • 93. TPE ) '(&# $% "! Disease Procedure Indication category Plasma exchange II Sydenham's chorea/pediatric autoimmune pneuropsychiatric disorders associated with streptococcal infections(PANDAS) Hematologic disease ABO-incompatible hematopoietic cell transplant Plasma exchange II (recipient) Erytherocytosis / polycythemia vera Erythrocytapheresis II Leukocytosis and thrombocytosis Cytapheresis I Thrombotic thrombocytopenic purpura Plasma exchange I Post-transfusion purpura Plasma exchange I Sickle cell diseases Red cell exchange I Myeloma / paraproteins / hyperviscosity Plasma exchange II Myeloma/acute renal failure Plasma exchange II Coagulation factor inhibitors Plasma exchange II Aplastic anemia/pure red cell aplasia Plasma exchange III Cutaneous T-cell lymphoma Photopheresis I Leukapheresis III Hemolytic disease of the newborn Plasma exchange III Platelet alloimmunization and refractoriness Plasma exchange III Immunoadsorption III Malaria / babesiosis Red cell exchange III Renal and metabolic disease Antiglomerular basement membrane antibody disease Plasma exchange I (Goodpasture's syndrome) Rapidly progressive glomerulonephritis Plasma exchange II Hemolytic-uremic syndrome Plasma exchange III Renal transplantation Rejection Plasma exchange IV Presensitization Plasma exchange III Reccurent focal glomerulosclerosis Plasma exchange III (continued)
  • 94. )* % & # $% "! Disease Procedure Indication category Heart transplant rejection Plasma exchange III Photopheresis III Acute Hepatic failure Plasma exchange III Familial hyper cholesterolemia Selective adsorption I Plasma exchange II Overdose poisoning Plasma exchange III Phytanic acid storage disease Plasma exchange I (Refsum's) Autoimmune and rheumatic disease Cryoglobulinemia Plasma exchange II Idiopathic thrombocytopenia purpura Immunoadsorption II Raynaud's phenomenon Plasma exchange III Vasculitis Plasma exchange III Autoimmune hemolytic anemia Plasma exchange III Rheumatoid arthritis Immunoadsorption II Lymphoplasmapheresis II Plasma exchange IV Scleroderma / progressive systemic Plasma exchange III sclerosis Systemic lupus erythematosus Plasma exchange III Category I = Standard acceptable therapy; Category II = sufficient evidence to suggest efficacy usually as adjunctive therapy; Category III = inconclusive evidence of efficacy or uncertain risk/benefit ratio; Category IV = lack of efficacy in controlled trials.
  • 95. TPE +, - $ . /0 ) GBS ':$ 523 7 8$ 9 & % 4 #5 6/- %23 # $ #3 1 0 U %0 Q RSA & T- 9. 3 8-H >PC ; J- - GBS 53 'XXXXX 'W( 4 -7 & 53 ;7 A U @" RSA 3SC = V " : U - 2 Y> Z 5 " M- %T- = 9 TA &) 9- - = & A 3 - J- . & , - =- [ . 5, ) > " * J .3 C -$ % T S _ S-A . %; ^ - % S-] 3 C & &,-/ %SLE %=-+N . - @ 5," ) . + %CMV, HSV %EBV 5 " 0 > & & ` a : & )," b& " 0 J ? T -]- 8 GBS 3- :& = , ," %b& " c & '2WDX Q & ) 3A M- 0 -J & 3 ; C d >O & c & )," a? - B . Y^ GBS & M- 5, - 1 & " -$ - % > &,U 5 f* >e & %3 d& aS L A 4 3 =+ & ) % ,1 RSA 68 - 5, J. = A ) ? - 0 $ - T- - 1 &,U 5, " " T- J & 0 g A& & 6-U d," . : 4 & gS 7 A % gS - = ;-$& & ) ,- V? h + 6 e &, , Y^ CL V 9 4 5, " KLM + 6 e d, ^ Q i J & lS % k 7 T-A& +7 6 7 8 5 " ), =-j & 3ESI ! 9 TA e & 0 S B A 3 =+ i L-i B,C N * % " 3A %3 =-S- U ,. 5 D%2 " ), GBS 0 J 4 3 4 68 & 8-H PC =-S- ) & - 4 Y . m GBS k 7 T-A = 8-H =-S- ,: S] , c+-A . 45 * n e7 o ? &kk S-] 3 C )g -$ 3 C [L % e 4 SI & , )," " - #$, S ]-7 -SC )," @-+M 4 Y^ U 53 )," ) K-LM Penner19 6 * 5 rWq 3 GM-1 =-S- , -Si * M k 4 p H7 *= c 4 ,Z E 9. Y^ U & 3 ? %GBS L $ >e SI , , - %GBS a- $ B A > - 53 s > %3 C >e U . & d $ , 0 C 3e1 t-? 3>? - %, ," B A > - 1 - Guillain-Barre syndrome
  • 96. 7>4 & 3 C w 1 & B&T7 d x e 3 U % A fu =- v 3e1 5 D%2 , 4 , N 53 ,- GBS T . %TPE ) . e IVIG IVIG &, M d O & . & TPE IVIG )," ) M -7 =J A , ?& C & >S? d +M & . [ , , y / e 4 # PL - ; % @ H @ ? - TPE 3>J , & =-7 S* S 8 5 zW'' 3 3U & , , & -> , invasive 1e 0 C - &) : C; & 8$ 3>J o 3 =+ +S , , ,- d O e .,-/& +- 5," >e d P - - S8 8 , TPE 5 '( , 0 $ n c A 6 e J& - & ,. --u - 9. & +S C M- 0 U % 0 U @ " U TPE 3 5 " + 6 e ; J- iJ& 9. n % +- + rW{ @ " . -]- 6 5 " ;. - a- $ B A > - 5," & }W'2 Q ;nU 'W '|r & 'XW'2 @? ,U & * B n B , = ; C I4 & '2 ~ C , & '{W(' - •'X 53 ) . C - U 6SU Qc A V8? %, ( gr/kg ) & r Q IVIG S 5 'D , " - C N 3 =+ c . =-7 S* B * '(X ) & r @ * S- {X A ," 5 " ) & ;JZ M GBS s > (XXD 0 ),"0 d 7 8 % AAN + 4 k 7& 4 <," d P 4 x $ ) .2 &, "> &, l H ? " -x -u7 • 5 " b& " - & ; C b& " , , " 3 T & ;/ C b& " , .( Q - , • 5 " A* E Y^ U ( Q &,"> &, = A ) ? " -x -u7 IVIG • 5 " b& " ; C em , .2 53 ;. 0 IVIG & d O • 5 " -x GBS ,-/& • - IVIG 0 > , immuno adsorption IVIG 0 > >- • 5 " -x GBS
  • 97. TPE 5 '2 , J. , ," GBS > . [ L .€& IVIG & • - 3 =+ GBS - 5 " ) = Ti 1 V C =- >74 - = %B & O 3 =+ N %, " " ICU U t-? • - 5, " , A0 $ - . , M- 8$ ~ )CIDP & 2 #5 6/- %23 # $ #3 1( 61 ), & M- 0 $ & " $ vM Y^ U 3 + k 7& - CIDP 9- 0 J & 0 -J & @H & . & ," JU & U 8-H w PC +S C GBS ` A ,. & ) ( 9- Q - 3A M- 5 > B, 1& i M 3 ,. 0 Z . 5 1& T- .c+SA ,ZA 9. 5, D M- - 5 'r 3 ,n ," -S- & ( =-S- i M w PC J - & =-S- Y^ - 5 & = M- *, ;M" & ;n 6. & " ), f c1 2 5 '{ , & 0 J d hC a : & ), M - . & ShC % " T c =-7 S* ~ . - =-S- & %@ " ;J- + 1& ,. " 1& & >PC . J - =-7 S* w %, A * ? - A ), 4 3 , T1 -SC 4 -$ d 7 8 5," % C L Tu V 0 S =-7 S* M CIDP > - e - Tubulin & P0 & P2 .=-j & ‚GM-1 @->? =-S- 5 '}W(X 3 ),M d >O . - 3SC & . 4 = O =- Q > i[-. 7& , ) <3 d x CIDP K-LM . - d x % Possible =+ k 7 T-A& +7 & -7 . A _ CIDP K-LM PC k 7 * d x & Probable @ H - CSF . A 3Z 8 53 definite 8? - 53 M )& * ;. o & 3 )," -x .)& * = %) & e7 - IBD @ i . - ) . & - , 3 =+ CIDP ), 0 S * HIV 3 C %=-+N . - %, > . 3A d^ $ %0 A = T 3- ]. 5 " 1 - Chronic Inflammatory Demyelinating Polyneuropathy 2 - Demyelination 3 - Remyelination 4 - Burning dysesthesias
  • 98. , 5, . o ^ Y >J ƒ ,-/& +- CIDP - SI ,- R , 3 „7 A 100 mg/day &,U 7&T- ) & @ " >7 5, 9. %3 A . & & Z @x U +S C O ,Z ;. IVIG . 5 (' , ? ,-/& +- d, ~ C~ - = 5 (( , ) M ,- CIDP 5 " B n %, J- e 4 @ H ? & , ) , o ,-/& - )g TPE % V8? c 7& % V - & )," I4 ) c - = >e & .( . 3 D% ;nU d P Y^ 5, " C N ) = Ti 1 V C •r =- >74 5 (' 3 , 6 .2 . 3 ( c] !ZA % + B,C d x 7& " ), 0& 6 . Q Y^ >e 5 " 2 d, @ 3 d x = , )," e M- -$ i @+ & 5 B & . ( d, B eN . & 3 ( B . ‚3 D B& . ‚3 2 0& . , n 0Q . , & DW{ - •qX €& = 5 * ;nU 3 . & 3 ), C - • {{ V8? 7& , >e em b& " (d x , & 'XW'2 Q c A SU { B n i @+ & 5 (D " i @+ & 5 (2 " ;nU 3 . & , ,- .2 . . 5 (r ," ;nU 3 .& . . 3 & Bn < ) MG & 7#9/ 1; a: 3 hCW >PC 0 P - & $ 0 $ c& * - 5 " KLM S+ d hC & . & s i J$ 5 " ), 0 {X ^ =- ?4 & 0 DX (X =- .; $ MG d P 3 =+ 7& 3 V " . E % & -& MN ^ c & * - 0 - w PC ! )," . PC d hC -* 5, A * .B , & d hC M 5 ({ " J 3 B,C & d H" VS @ " %; C = , ," n n S 1 _ - 0 $ =- N;. & - .), , 3 =+ c & * - ( ,U & ML -SC . 4 %MG > - SI 5," ) . - 1 % ShC 0 S e 6 H 6H x 1 ACh R =-7 @- ] 0 +7 1 - Myasthenia Gravis 2 - -subunit
  • 99. TPE 0P &,J @-7, %), -* L 3C 9 TA . 4= 5, J. M $ =-7 @- .), -* ->Q +S C V %), -* L S] - J+-A & =-7 @- 5 (q " ), - ,x zXW}r . 4 = 5 (} , " ' & =- i- j -E =-7 @- .), e 5, MG & & ( > n- &) e ShC & PC 0 P @H =-7 @- L =- i- &, - , ; J- ), w .& 5 " ), -? . ] & 4 +S C 9 TA ,: S . *g & t Q . ] - 4 9. ;. = - 4 & .,-/& +- 5 (z , -* ?) 4 … 8 9. & e 7 ,-/& - ," d^ A + & = ] S+- @ " MG , ,1 .& - > - - - ;. _ - = " U 1 5 DX , . 9. - - - ;. & 3 ^ MG > - - ;-$, - & T- ;-$, h 53 " - = e ,- d O %, " , - 1& ,. " AChR 4 - 9. > = N* , J , IVIG %d 7 8 D0 %X|2 gr/kg T- IVIG t T DWr . . 5 D'%D( " 5 DD 3 ) - % $€ * 1 =-7 @- , -* ,: 4 9. TPE >7 53 M* AchR ,: 4 ,Z 9. 0 > , ; C V >e n & A + d O ;. , " , " @ ? 4 - - - •'rW'X TPE ! k . 4 3 S8 = i - Y^ U 3 ) ) . T- 43-ZA €& & ) J* 8 TPE : U 0 U 5 D2 , J- K-LM @ ? _ dM 4 - - , ," †‡Y H-1 N * %3 )," V? & 0 >? MG BA - 5 " A * + %, @ H e4 , &) , o i e >e $ . , , %, J. > 3 U 3-S ? VS %c 3 B,C MG , ," , =- [ . TPE 5, J. 6-7& @U U% MA . ) & V ,- % + - Y x P$ % U 1 @ C 9- =+ ,U = e hC +S C , & % JS1 rW{ & d P ;nU 'W'|r MG , 5 (z ," =-7 & •r =- >74 Ti 1 . (W2 @x A Bn - $ ), ,ei %, J. - $ ~ C N =T 3 O - > - 5 (2%Dr%D{ ," 1 - Neostigmin 2 - Pyridostigmine
  • 100. 'W2 T- - $ 53 f + (WD . .) & 5 D} * ;-E - . - _ , & 53 f + . c A 5,M 0 Q ) 'W( !ZA Y^ &) ? >e ) & 3 ˆ@ ? +M n SI + . Bn 3J- d, ^ Q ,- S-$ 7& " ) - - T c A N * 5 " `& C - 5 DD%Dq 3 KLM 4 3SC , - - T n , =- [ . , 9 TA -iM- T- ; J- , w .& T . Y^ S8 R - A-Sepharose =-j & IgG L - wf1 5 " B n 4 U Q AChR 4KL wˆ 1 k )& * )& 3 ) ) . MG 4 B )," ) torpedo Californin AChR )," ,1 ,- ] , 5 Dz%2X , 3" S AChR-Ab = 5," Medisorba < / - = . #9/ 8$ 9 1! LEMS d& 5 " KLM a : & i J$ -7 p H7 LEMS 0 $ ; C V " % >7 & MN 7 ; C c& * - MG 5," - $ MA 9. & Q L . MI +M$ @ B - •}X 7 •{X 5, .E - j B, d P . 9- LEMS € T* T- . Q> & 1& s > N 0S Q & - = =- % " 3 C . hC W >PC ^ + & ; C % -J 53 )," 5 (}%2' 3 B,Z <MG LEMS > % 6 ? 5, >e 3-7 A & & Q &3 .‰>x M- LEMS ; C W . A . +M$ & ?4 (p @ "% $ ; J- +S C 0 $ W 53 LEMS V " ), TA o n - O rW} - O @+- 20-50 ^ 3C PC + H W 5 " ), ), . o - c+C 5, ShC @ C @-J facilitation b (VGCCs) k 7& 3 J & -JS .0 -SC 4 ,-7 @-7, LEMS W @ C ;. & hCW >PC B - 0 Z ;. -JS .0 = 5 * n N P/Q 1 - Lambert-Eaton Myasthenic syndrome 2 - Erectile impotence 3 - Voltage-gated Calcium Channels
  • 101. TPE 0 P 3-S ? IgG b . 4 " _ JU 5, J. -U B ; J- ,Z n- 5, * .0 = , 9. & L > e & " -JS .0 * S+ d hC a : > & A 9. - T V? )," 4 =-7 @- 5 2'%2( " ), T- B >PC . h +S C 0 $ =- [ . @ C @-J S C 5 2D , J. O MG LEMS =-7 .), e ' d ,? 3 =+ , ^ Q % k 7& J& - .0 l S t Q PC D&2 ) & %, ML >e =-7 @- . 9 TA t Q - = hC ( 5 22%2r 3 A* ? 1 & = O C =, - - 4 LEMS 3 =+ = - 4 & .,-/& +- , ; J- ), w .& . 5 2{ , . o ,: # $ 3 =+ - j & , " ,- 5 22 , ) € T* O %, J- > J - IVIG ) 3 0 & B 4 Y >7 I %MG 3>J o 53 )," 3 O LEMS TPE ,- d O LEMS TPE 53 ), - 4 >PC 6 >e 3e1 M- - 6 M 5 '%( 3 A * ? )& * ASFA & AABB , Z>Q _ <+ / A $ #=BC 8$ 9 1@ -SC $€ * 4 1& & ;-$, . ) . % >PC .B , , +A d --u %siezure - j 3-S- 7 J 5 2} , )," " % >PC ; J- T1 ANNAW' Hu 4 SI & " KLM $ ; J- & [L +S C 0 $ % mental 1 7 S- DqW2X k 4 -SC 4 %3 s > " ),- ;. D 5," Q N .0 S & e & 6 J. %, =- 3e1 _ * J- & 4T % J 4 n - j [L L - =- [ . & N 0S & J % , L . Q s> 3 =+ -SC 4 %€ * Yo 4 - •2X &,U 5 " n =-+N . 5, J. %," g e7 S 1 7 S- {( &D2 - . k 4 2 & . ;MN d U ; J- 0 $ _ S - W_ S J - j B, & & > . [ 3 =+ - = 5 " KLM C & ZA 3e1 1 -Voltage-gated Pottasium Channels 2 - 3,4 diaminopyridine 3 - Small cell lung carcinoma 4 - Paraneoplastic opsoclonus-Myoclonus syndrome
  • 102. J . Q . . 5, A - ` ) -I & J % . =-u7 4 " ),- ;. ANNA-2 Ri 4 3 =+ %, ) & S )i $ $ € * %3 >PC e7 S J. 1 7 S- qX & rr . k 4 -SC 5, " " - = 5 " - n , 3A & 3- JU GC Q !> - N .0 S Q & =- e& l M . k 4 -SC 4 CAR 4 5 2q%2z 3 !> %," U %0 4@ C $o d, e 4 53 @+M .B , = 5, . % i & . =- N;. & %, J. O i d e1 .& = & 53 ) ) . ), ,- R Y^ & 3 )," ) = , TPE 5 '%( -* ? )& * ASFA & AABB , Z>Q _ ) MS ' 3 EF /- & #=BC : >/ % % 4 %23 $ 5 1D >PC +S C 0 $ GC 3 CNS =-S- & - Y^ U - MS A 4 b -" % O p H7 53 8-H & O A& MS 5 " )T-7 7 9 TA -A u1 ~ C 9 TA 4 b -" 8-H p H7 & 3 M- , J. HLA-DR2 %, d 1 e 8$ tQ 8$; tQ 0 'r ; = A &, 5 rXWr( , 3- > 3- 1 6Z8 8$ 0 U %;S+ 0 $ %_ * J- % - & % - a : % . RSA %a : @ " MS - . *g & 5, " Q C >O & +S C 0 $ % J 4 %3 U 0 U >J 8 , U . S U - •}X &,U %3 T @ ? -7 & n , 3A M- •DX 6-Z 5 ), " € $W), C , >e Q @ 5 = T , & M- , J. - B& , & 9. @ - & Q MS , " € $W), Cb S U w& 5 rD%r2 , . i7 --u = T , & M- b 3 =+ - h 5," MS - k7 Sx 3 C %,- )," =-S- Tn .l 3A M- & >-A 3 c] & ) e7 , %, " ), MRI 4 U = @-$ ; J- % " = =-PPL SI 7& 3 $ " e 4 . E ;J- + 5, 1 - Multiple Sclerosis
  • 103. TPE 5," .l T –cell 1& @-7, 7S o 37 $ , . M S>? d 7 8 & J 5 r2%rr MS 0 . ; J- T - 9Z 37^ -$ d 7 8 @-+M MS & _ % ; J- , @ , & ), w .& d U >e n - & +- 4 . & ,-/& +- ) .) & 5 , . w e 7 & B 9. 68 & & 3 ,. V 3M* GC 3 =+ @ C = 5 " U a? @ C = ! 6 ?& 3A M- 4 7vJ = 5 rD , " , ,1 .l F Q 3 * @$ .,-/& ? ) N * 53 , -$ " 5 r{%r} , - -$v ? & MS b& " 3 =+ %3 MS & 6 - 9- SI - @ i -J - .& & ,-/ 7 ; J- @ %= ] S+- d 8$ @ Z 3 =+ & " ! ,U ,- d O e %,- JA S+- & = - 4 ( ? ;. ; ƒ =-> & dJ & & ' & J - 5," € ,? A e 4 & U d U w& %@ C = %3 ) ) . ), &,- .o ;. IFN- 5, A * C d A 9. Glatiramer-acetate =- [ . 5, . 9. MRI , ,1 d : em 5 rq%rz 3 O ) ZC @ ^ 5 {X * d U w& 9. n T- IVIG - -A& T n d U k7- $€ * A3 M , ,. " %3 ;e> MS TPE 0 >, h R )," B n . & 1& - = T 3A M- & U T- , ," .; k U TPE 3 T ),"0 d 78 0 U . 5 {'%{( , " 3H ), & M- MS > - (X =- 0 5 {D%{2 3 d >O @ ? L , A * ? T- 3H T . 8 'X %, " ?0 d, = - 4 & & %)," 0 78 5 {2 , " , M- >e 0 )& * 3>J & &T- TPE ) . - %), & M- = T MS > - r2 =- A P 78 = >7 5 {( , " e >e 3- :& , ) ,- JA S+- 5 {r%{{ ^ +" 1 5 {}%{q , i € T* TPE ) T Š-. , )," 0 78 & N * 5 rq%rz " -x ), & M- MS % 4 , 3>J TPE d 8$ & T. MS .)& * h TPE ) ,- 'zzr 0 )," M 78 W), C & ), & M- MS b AABB & ASFA , Z>Q _ 7& 5 {z e M- 1 - Mitoxantrone 2 - Cladribine
  • 104. TPE ,) e M- aS L d 7 8 >7 (%' 5, ? Z>Q ), " € $ }X%}' %r}Wrz ," , MS d, ^ Q & , ," d U > - %, ) , o ; J- i .& - d 78 h - d 78 = _ 5 }( 3 - b ?& V - >e TPE B n c & •r =- >74 ;nU JS1 . & A * ? TPE JS1 'X 3H - & - & d P ;nU '|r i d 78 h 5 " = Ti 1 =-7 5 D2 3 )," ) .{ . c] & . & < 3 # 7 #H # $ 1G $€ * 0 S =-7 S* & S > - •'X &,U }X ^ =-u7 • D & 0 rX ^ =-u7 •' % e -j & =- N & T- 5, J. $ % =-S- !> =-j & +-S* MAG & d ,-. ‹ -SC 4 5 }D ," 0 & =-S- P0 =-j & +-S* & M ‹ 5 " 3A IgM J& . & 3 ! =-S- ,: 4 3-7 A 5 " ), >PC .0 S MI ., -Si * i 4 t T =- N ;. 5 " V J & > - -J 0 S .=-j & -SC . 4 - 5 =- =-S- % . iM 4 d -U MAG , -Si * GM1 & MI !> C d 7 =- & , . 9L %=-S- F I . ,- 7 5 D{ 1& ; C , N . %3 CIDP ->" 0 S * !> & -7 d . E SI V " L $ >e & ) , ," - S 8 & , - 3A M- % JU 5 }2 ," e 53 V " %IgA IgG *, 3>J IgM .=-j & - & -J IgG IgA .=-j & & b -" 4 3 - & S+ j S- &0 S =-j & % &, % 7 i * % & S POEMS B , /T1 . * & ^ ), >-A = A 3 & J4 L %=-S- ,ZA % PC J - 5," d --u 5,. M IgM !> - S] & IgM 3 =+ c SA 5 " , B& " ,7 & -7 S*& S- @ B-cell . -$, > - 5 " @x U ;. & >e 3 =+ & , " -" .@ &
  • 105. TPE ' &, MGUS KLM 3-. 0 S * )& C & - -J 5 }D , * % " ) + CIDP [4 M i @ C >e M d 7 8 & }r 3 )," € T* O %MGUS J& & TPE @+ & 53 ) e S-$ IgM J Z IgG & IgA 0 S .=-j & - . Q ," & 'XW'2 Q JS1 rW{ @ " - = & AABB , Z>Q _ 5 (2 * = Ti 1 =-7 & •r =- >74 ;nU JS1 ) . & +-7 U )& * IgA IgG 0 S .=-j & ) . & ASFA 5 '%( -* ? )& * IgM 0 S .=-j & < #=BC M/N L % 5#/ K 5 + / A J . /0 1I C c SI & & 3 J 0 $ Rasmussen 3-7 J ( F $ %," g- d x - = 7 I -7 . E 5 " b& " & & ), & M- >PC K Z N Rasmussen 3-7 J > - % - , bx > - & we 7 k7 J-. d 7 8 5, " =.ˆ * A ZC & . @ " A 8+ SI & 5 }{ ,. M 3 )+ - &,H SI %Tu 3A A& 4 CNS =- S* - J & !> Glu R3 ] -SC IgG 4%. VQ Z 9 & @-7, . 4 = 3 )," … 8 -: A = 5, ) M $€ * w& IVIG & .,-/& ) . %c A 5 }} , " n & +- k 4 o 53 ) O - $ >PC ; J- +S C >e & ) 9. g- d U =-7 & •r =- >74 ) & 'XW'( Q ;nU rW{ 0& SU + & = $4 , Sx A 'gr/kg IVIG t T 4 0 > , & = Ti 1 V Sx A ,-/& t T & " + ) (WD . )& = 0 U 5," %, & 4 - = AABB & ASFA , Z>Q _ 5 }{%}q , ^ Q @U =- 5 '%( ? )& * 1 - Monoclonal gammopathy of undetermined significance: B& " ,7 & -7 S*& & @]- 7 B S- P-LM . - &, 0 S * 5 " * 2 - Siezure
  • 106. Q6/ ?C Q5 R= Q Q?S #Q $ #=BQC #Q9 % Q0 . /0 86 P 1O <# / / ? T . & >PC d^ $ , >C PANDAS & B e ,- GABHS , .3 C b ?& 5 }z%qX , . & GABHS 2A )& * .3 C 5 " . - = 3 $& 9 TA n %PANDAS & B e ,- > - 3 J- & 6-7& K-LM 4 1& & 3 J- & Sx d . E B e ,- d U 3 ),M 0 ) d U 1& & hC a : @ " - = 5, S+ 0 $ % - 3 -" A %= A ) n. n &, @$ , & U0 $ B & ; C5 " B e ,- = * =L n d P d S & & +A %T 9. % >" _ % Q C >O , >C , & 4 9- Y >7 I 5 ,1 w 8: 68 & L 3SC 0 . -Si * w e 7 Y^ U B e ,- k 7 T-A 0 -Si * e & VQ Z 9 & & , " $ GABHS -SC . 4! %i U d^ $ b & J- %B e ,- > 5," %, 0Q . 4 = - 9 TA 53 ) M 0 . -Si * e & ,: 4 q'%q( , Q > U d^ $ d," & d, D € 0 $ & OCD 1& 3 OCD & d^ $ .& * PANDAS & GABHS 3 C s > %; C ) & 3-. %Œ S 9- ; C b& " % tic) hC 5 qX * KLM %B e ,- , . Q k 7& . n. r 2 & c & ]7 & % 0&, 7 . @ =- & , &,J .& %B e ,- .) , e .OCD 5 }z , " U ; C d," 9. > 3 {=- =- & wf1 .), e 5 -* d x =- & , &,J .& T- & =- & wf1 5 qD , " & ; C >J =-+J n !ZA 5, O - •}r 1 - PANDAS: Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection 2 - Group A -hemolytic streptococcal 3 - Obsessive-Compulsive disorders 4 - Haloperidol 5 - Divalproex 6 - Carbamazepine
  • 107. TPE TPE %," 4 J & 0 $ & . k 7 T-A , E n4 d^ $ = TPE ,- d O , . M )," B n . 5& + & . & ASFA , Z>Q _ 53 ) ; C >e , =- [ . & hC € >e )g ? )& * O E PANDAS & B e ,- ) - AABB TPE d O 7& 3 ) ) . 3-ZA d^ $ = ;. IVIG 5 '%( , -* 3 C 3SC ? - $ 53 ) IVIG 3>J d hC € >e >e "; C IVIG )& + %, ," ; C 3 $& N GABHS B n ) & 'XW'( & Q SU rW{ - & & . Y^ 53A •r =- >74 ) = Ti 1 V & ;nU 0 3 . T- 5 " !> OCD > - 3 ˆ B ^ 5 qD ," =-7 & 5 q2 3" , -O Š-. , ) > .3 C
  • 108. ASFA 95* =S T 5 # $% 8U "@ )!O&+ , - $ $ 5 $% AABB Indication Disease Procedure category Guillian-Barre syndrome Plasma exchange I Chronic inflammatory Plasma exchange I demyelinating Polyradiculoneuropathy Polyneuropathy with IgG/IgA Plasma exchange I monoclonal protein Polyneuropathy with IgM Plasma exchange II monoclonal protein Myasthenia gravis Plasma exchange I Stiff-person syndrome Plasma exchange III Lambert-Eaton myasthenic Plasma exchange II syndrome Paraneoplastic Neurologic Plasma exchange III syndrome Polymyositis or dermatomyositis Plasma exchange III Leukapheresis IV Multiple sclerosis Plasma exchange III Idiopathic inflammatory Plasma exchange II demyelinating disease Refsum's disease Plasma exchange III Rasmussen's encephalitis Plasma exchange III Sydenham's chorea Plasma exchange II PANDAS Plasma exchange II PANDAS = pediatric autoimmune pneuropsychiatric disorders associated with streptococcal infections
  • 109. TPE # S # 0 . /0 % " + c A4 ! Y -Z J , . 9- 3 * $ 53 A + Q & $ d^ $ b TPE n- (TTP& ' $ $ +9 / = + = 1 +S C 0 $ % % - > & % - g 4& +- - -7 . 4 3 - TTP KLM %, " ), A M- 3 =+ % -S +S C d^ $ 1 & CNS @-+M TTP > - •}X 5 qr 3 -S , ," N * 5 * T ? .0 >S* & 3- J-" 1& % - >& )& C . iM 4 d^ $ 5 q{ , . P = ;I SC %3 k& ,-. d ^ LDH 9 TA T- & 8-H $ - J. " +J O " A • M ), 4 @ C . %3 T-7 . " 5 q}%qq ," . * -/ `& C ,J - , B A %=-u7 TTP B A = V " 5, , ;-JZ ;. Y , C HUS2 & TTP %2=- c- %D=-J - @->? .& & .3- J @ " i @SC 53 % - . .0 S , - % Valacyclover %OCP %= , S+- %=- - %_ -7& %= ] S+- %SLE %,-]-7 JA 4 4 B , @ - . - % , & 5 qz%zX ," k .& E-Coli " )," n $0e , & AIDS % & S+ ) M .y & . > & %TTP > .3A k 7 J-. vWF) , >S & A A&3 &U . > & = 3 ) M -" J-. 53 ; T4 > ,ZA %TTP e M- c T k 5 z' , J. = >-A , & { r A A =-i . 7 %3 vWFWCP ADAMTS13 C 3H =-j & 7 } A =-i . 7 5, +" 0 -S &, e7 S ! H" ULvWF , >S & = ! %, " . $€ * ?& & , ? B -S &, & ->Q Q , >S & A 5 z' " J+" +N d 8? j& 1 - Thrombotic thrombocytopenic purpura 2 - Hemolytic uremic syndrome 3 - Mitomycin 4 - Cisplatin 5 - A Disintegrin And Metalloprotease With Thrombospondin type motifs 6 - vWF cleaving protease 7 - Unusually Large vWF Multimers
  • 110. , >S & A A =-i . 7 % - - @& 3 ) M . , .3 V? & Ib IX=-j & +-S* @ . 7 = 5, € * - Y e & )," 0 -S &, e7 S & i ,+ .3 *, >JN 9 TA GC Y H: & & .0 >S* +- + & n- & ^ + && +- . ,J & A P - >& n 5 z( , " -U . * +J & d1 &T ? TTP & w& TTP % - , -7& TTP > - 4 3 )," 3 O 1 TTP 5 zDWzr " j & ; T 4 3-7 A 9. > 1& = , S+- " 1& ; T 4 = O > Y^ U f7 & ) 0 A -I 4 1& &, vWF-CP ; T 4 = T Š-. %HIV O Y^ U & = , S+- F P J& T1 O TTP 5 z( -J " P 53 ),M 3 O 4 hU & ; T 4 O KZ & " , >S & A A =-i . 7 . n B -S &, 4 - 4 % O TTP 5 z{ , >SI j & 3-7 A 3 =+ TTP$% # >V K */ 8-H $ - 5 1& - > & & - g 4& +- - -7 . 4 CBC , J. T ? .0 >S* & )," J+" T ? .0 >S* 3- J-" % - 7 +- 0 k >-A 3ESI & PT, PTT k 7 . & Z 5, " ), % , J- ( 53 (DAT) ;-Z J =-7 S* 4 9 4 & , /T1 9 TA D-Dimer & FDP1 %3 <i eJ . * & B =- S* . , ," 9. %;-Z J -I =- & S- 9 TA %B LDH , ," 9 TA &, - g 4& +- - -7 . 4& - > & e 5 " ), B =- - 9 TA b& " & K-LM _,U ;-$, $ MA 9 TA & DIC @ i -7 @^ 5 z}%zq 3 A •zX 9- TTP - & y T- %3 c A %TTP -7& 4 9Z & 3 TTP - , TPE -O = M- 53 ) 9. •(X FfU >- %TPE ;J- + , E 53 KLM , , j & KZ TTP O Tn 3 -j & & , >S & A A =-i . 7 FfU % 4 ? HUS & $ - e7 S , - ? )," n HUS & TTP B , 1 - Fibrin degradation product 2 - Direct Antiglobulin Test
  • 111. TPE -x Plasma exchange TTP > - . %. [ 0e 5 zz%'XX " FFP ) ;nU '|r ! Q ;nU 'W( & @ " TTP -7& +- T. 'XXW'rX 9- € " i . 5," = Ti 1 V C 3- :& x 5 'X(%'X' ," " , 1& k 7& +S C 0 $ & " ->Q LDH & n , 9. %," " d >O 3C (2W2q - n , 9. ), A 3" 1 , >7 5 'X( - & d x 0 > , 3 =+ n4 7& 'XD ,M ),. M & d 7 8 $ & ),M 3 O +"T -J %, " - ; C e* 3 $& N - %TPE B i . & & e* V8? , % k 7& 3- :& t-? 9 0 U . 5 'X' , -x n , 9. - 5 "Bn 4 c & =-U , LDH& .3 - h & ," ,- 3 =+ CPP ,? A %, . o FFP 5 'X2 " - 9&A n 0 '|r B LDH ‰8 9. & >PC ; C >e o ; C =-7& 8 -S +S C >e 5 f* 9 TA & € " & = , N , & & 'WD Q ,- T-7 - - U S U Q - U ,. Ž - 9- @ ? -I & @ -J 0 U e 5 " V8? T-7 , >e ,U Y^ - •'{ , , d^ $ = 5, ? , $ MA 9 TA & -S +S C ), -? 0 $ - 5 'Xr , J- c A d&: Tn %," O ) , 3 d >C i €& - AV , FFP ;E t T j & O KZ = T 1 TTP % ! " ) 4 Sx A - 3- :& >e t T 5 " 3>J ML O % M- 3SC 53 ), C , , V - 53 O e 3 =+ 5 ) 3? 8 20-30 ml/kg/day ^ Jk& , %,. Ž $ € * 3 •}' , ," 3 % A 0 >, b & " ),. M M- 9. +J & ] . > - A - s> 5 'X{ ," ) )i 4 vWF =-i . 7 1& 3SC Ti 1 / " ) _,U Cryoprecipitate T n 3SC =- . 5, , ,M . > & ,-7 f7 & , 9.
  • 112. &@ =- & )," 0 7& 5 ,. $ O ),"3" 4 vWF VIII A & k >-A > % " ) cryoprecipitate * 5, i ),. M Cryoprecipitate )& * ! )," B n 5 'X}%'Xq FQ @ w& ) , ' ; J- , 7& , * ) = Ti 1 CPP (CASG) c A4 78 n ) &,H PTT 9 4 * # PL 5 " 0 k >-A & PTT %PT d M 4 Z 5 ") T- FFP CPP ) . , &n % 'Xz 3 ,: .& % 'X' .,-/& +- @ *w @ C b . C ''D IVIG % ''( A = ] S+- % ''' + S] % ''X =- J = & -O e 0 , - & = ] 4 @ 3 4@ C ) 5, )," … 8 + 5 ''2 " , ,M ML O = &TA 7& 5 , d x & & '(r mg 7&T- @- $ 'mg/kg/day 7&T- ) =-7 S* & =- J = & T n i €& 53 0 ) . , & d 78 $ 53 )," ) ;. = ]. & + S] B& Z - 53 , & 53 " $ -O ," c] & ,-/& ) . * # PL + S] ) - . - ) .TTP 5 1& -J , = ]. -O 53 )," -x = - 4 & ,- JA S+- %= ] S+- % &T- F P ADAMTS13 ,: 4 ^ - @-7, ADAMTS13 , ," > " ,1 , - @ C A: - , " n , i ),. M .3 , 9 TA & =, N c - 5 T n Y^ U %, C e4 - >& V8? 9. , - & , M- >PC ; C & , ," - - 5," , e 4 .,-/ +- S* - ) . ,-/& ;I SC & , . o & 5 ''rW''} , > , ," - 3 =+ % " , ,M e 4 5 '%( ? )& * TPE - + , E AABB• & ASFA , Z>Q _ TTP ADAMTS13 ; T 4 > @-7, 3 - . [ = T 1 TTP - &, " ;E t Q ; T 4 Ti 1 - = 5 " n 5 ''q , , c A 1 - Canadian Apheresis Study Group
  • 113. TPE ) O& TTP $ 5: X8 U Y- H Z / " D W Study Response Refractory Exacerbation Late No. of (%) (%) (%) Relapse TPEs (%) Rose/Eldor, 30/38 (79) 8/38 (21) NA 12/30 NA 1987 (40) Onundarson, 21/27(78) 6/27(22) 7/27(22) 2/27(7) 7-19 1992 (mean) CASG,Rock, 40/51(78)* 11/51(22)* NA 17/63 16 1992 (27) (median) USTTP, 103/115(90) 12/115(10) 25/103(24) 13/103 NA Banderenko/ (13) Brecher, 1998 Vesely, 38/48(83) 10/48(21) 17/38(45) 8/38 17 2003§ (21) (median) Total 232/278(83) 46/278(17) 49/168(29) 52/261 (20) * Plasma exchange arm only. Includes both arms of Study, plasma exchange and plasma infusion Remission rate 70% by day 2130% … additional 1-2 weeks to respond. Idiopathic TTP-HUS only. § TPE= therapeutic plasma exchange. Exacerbation= recurrent thrombocytopenia and resumption of TPE during hospitalization ( Onundarson), within 2 weeks of discontinuing TPE ( USTTP) , or within 1-3 days of achieving remission( Vesely) ) HUS & 8$ 9 + $ + / - 1( a- $ - >& & -S U% - g 4& +- - -7 . $; HUS -]- 4 & - ,- -]- & =-u7 & . [ - , HUS 5 " KLM ! Shigella & E Coli O:157H:7 , =-J & & ,7 . - ,- HUS 5, " ;-JZ ( HUS M- " * T- D+ 0 e ) . - ,- HUS 53 !> - h , N . 5 " ), ; -J =-u7 HUS b = c+C 5,. @-+M & 0 -S- A B A & =-u7 HUS 5 '(X%'(' ,. Ž T- D- 0 e &, , - & 0 >, - , 3 =+ 0 -S- A -I B A 5 '(( ,. & 0 -S- A -I c Tk ," P , , e , % +- S ; C M 3SC 5 z} ," - .0 S 1 - Hemolytic Uremic Syndrome 2 - Diarrhea positive
  • 114. 0e &, HUS A =-j & & TPE %_ = f7 %3 TTP M HUS 53 )," -x =-u7 HUS & D- % - .0 S , - 0 > , HUS % . [ 0e ? HUS . 7 ), +" j & ,Z ), 4 @ C . 5 zz , . i 1 A j & ,Z & 3 ) Z TTP 4 l M ;J- + %HUS , >S & A A =-i , ," > N - !ZA & 3 A 9. 0 ,U - = )," "H S] A KZ %0 -S- A HUS > - h 5 ''z , J. @-7 7& ," HUS TPE Z8 S-7 3 =+ 7 J = 5 '(D%'(2 3 B, e M @/ J 53 ), $ " [ . HUS TPE +- S d . E S U 3 9. & ,> .; T 4 9 TA %T-7 . @ " 'HELLP E AABB & ASFA , Z>Q _ 53 … 8 % J] ) & HUS %TTP e M 5 '%( 3 KLM HELLP B , 4 9Z & )& * HUS - +, < 3 2A 1; C 0 S .=-7 S* !> i B, 2 % 8-H & ) C <, ), 4 0&,1 B , r = 5, A * ? 1 TPE +- -S . - +, 5 R= $ 5 $% TPE 8U "G ) (@&2 A $ Indication Implicated Ig classes Hyperviscosity IgM>IgG /IgA Coagulopathy IgM> IgA>IgG Myeloma Kidney light chains Neuropathy IgM>IgG /IgA Cryoglobulinemia Type I IgM / IgG /IgA Type II IgM >> IgG /IgA 1 - HELLP: Hemolysis, Elevated liver enzyme, low platelets
  • 115. TPE < */ N F 8$ 9 c A ! 3-ZA - :& =-7& % +J & ] . B , T $ d^ $ % >PC ; C @ " -C B B , 5 '({ %'(} ," % TPE - 9- 7& ] . ;nU 9 TA & B & T $ B - % € * ) i & .s L ), . 5 '(q ," S? Z U B• & ;nU 9 TA J& =-7 S* @]- 7 B S- - •rX +J & ] . B , IgM B& " ,7 & -7 S*& > - •rXW}X & , J. IgA IgG b 5 " ), =-7 S* 0 S S 9 TA Y , - = 5 '(q %'(z ,. & %, J. +J & ] . B , ->Q -I + T-A d PLM =-j & =-j & Z 1& & .y ,J n & " $ 6 +J & 9 TA > T ? .0 >S* w t Q ,U & 2W{ +J & ,. Ž ?& Y^ ; C 5 '(z * , .B , +J ( 3 =+ - h 3 ,7 ,U & '|rW'|q ->Q +J & , 9 TA ,7 3ESI + =-C +J & 5, " 3 C ,? A +J & & =-j & -J T- E 53 J & ;. =-j & 3-. % ,C P 8 4 & " i J =-j & > 4 3ESI l, d --u %=-j & 3ESI PLM ,U c 3 = ,C P 8 -+ c A ,U & & n- 5 'DX " +J & 9. 9 TA %," A ; C VA ,U A 9 TA +J & 3J 'zrX . 1 5,. 9. ,-7 9. & ) d, 0& F,. 53 9L & @ " +J & ] . B , `& C $ 1 >e & =-j & 3ESI 9. B& F,. 53 -" =-j & =- >74 Ti 1 ;nU 'W'|r = 5 " J- TPE & %," +J & ] . B , ,. M d 7 8 5 " B n =-7 & =- >74 0 ;nU •r -7 S- 'XXX 3A t Q •'rW(X IgM @ ,Z 9. %IgM 0 S =-j & " 3 =+ ;nU 'W( f7 % 'DX , ; •rX 9- >J +J & @ 8 Y > Z IgM %, 3 +J & >e 3e1 =-j & A T- ‘ $ =- . & , 1& T- ?& C ‘ $ hA IgA IgG .=-j & %3 ?& C @$ F,. 5 D2 ," M- , BTS J 3 =+ .=-j & T- 9. @-7 1 - Hyperviscosity syndrome 2 - Ostwald
  • 116. 5 " ;-E - - JU , d A & 3 ; C FQ 5 'D' , E A TPE & Bn -7 S*& " +J & ] . d, ^ Q 0 e c A + % B& Z B& " ,7 & -7 S*& =-7 S* 1& @-7 3 ˆ B ^ 5 D2 3 A + 0 '} +J & ] . " % " 7& ]-. N ? 3 =+ - %@]- 7 B S- ?& C ‘ $ 53 ?& C ‘ $ hA ^ - + MA 3SC ?& C @$ hA V 3 U ,. Ž , 3M* @ ? -I d --u 7& , 9. B +J & 9. ; C 5, A ` S$ € * , & > & 3SC Y^ U 3M* @ ? -I " , %i w -I c A V8? c 5 f* -O - & c A E AABB & ASFA , Z>Q _ 5 'DX " . (WD Q ; C C n 5 '%( ? )& * +J & ] . B , TPE - + , <# - 7 U 3 =+ Z . A&3 @ Z +S C =-j & e7 +7 37 $ •2X % -7 S*& > - •{X . 7 * 5,. & ;. +J & ] . w -I d >O c % = 5 " 3A IgG S- - •'r & IgA S- - 5 '(r , 3 ,U .’ U , TPE % -7 <# 3 * 3 T 1 c =-j & 4 > .) -n @]- 7 B S- > - -S B S- . iM 4 . A B -S U - = 5 " ), %, ‰" $ & " ), @]- 7 B S- > • DWz -S B S- 5 " KLM E > .) -n - S-A @-7 -S B S- 5 'D(W'D2 3 $ , e*49- T- & .0 b J n Y e 7J = 5 " n -S e7 w B 0 S 5 * -S & 7 A& 4 F $ 5, 3- . 7 ;-Z J 3- J & 7 @$ , S- n A& B S- K-LM 5 , - Q> > -n . *g & T- +J & ] . B , - - , : C= n -iM- 5 -* d x -S J - _ -S VA % 0 +S C -S 5 " -S? %=-j & VA 9 TA 3e1 & )," c 7& % " ‘ $ TPE ! , 3 ,Z 9- -J > -n > .) -n T- 9. 53J. .) -n = VA + €& - -S
  • 117. TPE c] & " B n -S J - * 5 'D2 %'Dr ," T-7 O % 1 1& Z . A 3" 3SC J - , T $ J % " b& " c A 5 9. Z 0 $ , % =- >74 n )," " V >J Ti 1 1& 0 S > ) -n ," O ?& e 3 =+ c A 5,. 5 " ), B =-j & A& +7 =-7 S* -U M - 3 ? = & +S C 3M* iM . %@]- 7 B S- -S a- : e*49- ;I SC % -S B S- 5 'D{% 'D} , ) TPE & -" B T-7 - -S =- - % -* d x . eN d, % . D & d x % , 5, >e -S +S C . M & =- - c -S %BUN %B 5 '(z -* d x -S +S C ’ U 3e1 %B&T7 B S- " -S TPE - + , E AABB & ASFA , Z>Q _ 5 '%( ? )& * @]- 7 < 0 / [ Y/ $ $ 1! , ," - >& 3 7 $ PTP $ 0Z ? %,. Ž k 74 $ .) &4 A 0 Z c & rW'2 -7& +- 3 'XXXX @+" T $5 " F Q L $ . (W{ ~ C e - > & 5 " KLM V " @74 ,? A > A SI 5 'D' %'Dq 3 -u n 1 @$ , M k . B 3 xP $ k 4 SI &3 # $ =-j & +-S* e k 4 + 5 'Dq , " (GP) IIIa =-j & +-S* & % ," ),- PLA1 >? HPA-1a 53 )," € T* T- HPA-5b %HPA-4a %HPA-3b %HPA-3a %HPA-2b %HPA-1b -SC 4 , . iS U Z - SI 5 'D' 3 !> HLA-A2 =- [ . 37 U = # PL k 4 n- &, " S>? , . k-J , J. A & S>? #$ 4 74 o PTP N * 5, )," )T- % " , V " @74 ! 3 ), B S k 4y7 e ,U 9- L ;J- + % ' 3 s < 'Dz , )," e M- ;J- + ), , = -1 %3 1 - Post transfusion purpura
  • 118. .@+- & +- 3 . + d P )," @Z . k 4 74 < .c+S] 1 , n %, " ,-7 >? . 4 74 0P .c+S] 5," y7 .3 0P >- @- , .3 )," 4 t Q )," @Z . k 4 74 < J . k 4 1( >? . 4 74 ! ,. ) 1 & , >JN y7 .3 J 5, " _ JU " ,-7 @Z .3 % k 4 74 x P $ 4 H )& C < 4 @-+M 1; .3 & )i 1 -SC xP $ 4 . + )," Z7 > 3 5, " y 7 n & A * d x 0 HQ ! .3 FfU %3 3 E B, + EF x 5 'Dq , n 0 Q ) " - >& ƒ .,-/& +- 5 " -x ), M . T $ & -* S1 PTP & )," -x PTP % '2'W'2D & r & X|2 gr/kg IVIG ^ & % '2X ^ U 6SU Q k 4 ,. U3 t T 5, " € " 9 TA GC , ," .9 & n n 3 =+ +S ,. 9 TA € " e - _ ) = IVIG ) o d, 0 Q & 3C 1 5 * T- 5 * ) , , o `A - TPE & ? PTP , V 9 TA > d " T* Q & 3 ) ) . .3-ZA PTP TPE € " ,- 3C (2W 2q . ;nU d P SI 5 " .3 V C =- >74 Y >7 I 5 '22 -* B n = 9- & -7& +- (XXXX =+ f7 1& Z d^ $ @-7, T $ 8$ - = 5 " ) = Ti 1 C5 ") & + ? 7* & -* S1 3e1 FFP 3 -7& - >& Y^ N * %,. Ž V8? ? 3 =+ - >& 53 a- $ 5 '% ( ? )& * TPE - + , E PTP - ASFA & AABB , Z>Q _ < % Y $ / : 99 $ 6 "@ T1 -SC Y -Z J , J. IgG c 1 . 4% Z A .), e e 4 5, " Z d^ $ > E A 0 A -I & , " Z M4 1 - Coagulation Factor Inhibitors
  • 119. TPE d^ $ &, A . 4 5, " 4 74 & 4 b & + 3 =+ & - -7& 7 d^ $ % - . - % iS U & ) & S>? , . T $ , -SC & ) - , . 4 = M SI & , . . & .9 & 5 '2r% '2{ , @ C VIII A Y >7 I Z . A e1 6n- C % Z . A +- k > > - %. 4 74 = 5 * ,-7 % " ) + = Ti 1 . A 1 $ =-j & 5, 1& B S-A . - ,x & A S-A . - • 'XW'r . 4 74 . . 4 ! Y >7 I 3 Z =-j & %VIII A " EU + 8 . A 4 % S-A . F $ 7& " V? & -O 3H b = > - 5 " SP T $ > & ) B 3A T $ ) .VIII c] & T $ d U 0 3JL <3 SU ( @ " .), e = " T $ 5 .), e 3$ w - @ ? .€& + BU ,J ,U & ), e - _ 3JL F,. IU/Kg) J VIII A ^ . ƒ t T %," ,J ,U & r 4 - * 53 VIII A ^ ,J ,U & rWrX Z 5 " - 3? 0 > ('XX J VIII A ,: . 4 , VQ Z 9 & Y^ rXW'rXIU/Kg $ @ VIII A , By pass d^ PH % . - = ^ ,U & rX 9- Z & 0 $ , Ti 1 TPE 5 '2}% '2q , " - VIIa A J Z T VIII A + Q ,. 9. B ^ ,U .), e - T $ 6S U 5,., % . n & $€ * , ) 1 $ ^ ƒ @ i @ C ! 3 .), e ,-7 w B& F,. 5, 4 3 , 'r' IVIG & 'rX =“ “] “S+- % '2z -J - @ C % .,-/& +- ' - 74 .), e > - @ H , Z7 .@+ & 'rD , " B n k&T* VIII A & ;E t T e 53 )," -x %, J. 9. A –Sepharose =-j & IgG … 8 9. TPE %Malmo @+ & 5 'r(% ? $€ * , )," t T A " ) b& " ), e - 5 'r2 , 1 - Tolerance
  • 120. T $0 6-7& .€& ),M 0 T $ > - %TPE = A 3>J o >e > ? U 1 - ) 4 3e1 %, ) , o - 9. 3e1 c 7 n & ;-E .; k =- [ . & " Z T VIII @ " 0 .€& 5 % $ € * VIII A M- Z 4 6- ”? 7* 8$ -* S1 3e1 FFP Ti 1 % ;nU (WD 3SC 3 - h T , & 5," - .0 $ ) - SI & 3 GH N;. % - B& Z , . T $ d^ $ , Z>Q _ 'rr 5 1& ;$ T $ a? VIII A , By pass & A , -* ? )& * TPE - + , E Z A .), e AABB & ASFA 5 ' %( ' 5 'r{ 3 )," € T* T- ,-]-7 JA ,: . 4 - =- [ . TPE = AABB & ASFA S 8 5 'r} , J- @/ ? €& = MZ d 7 8 h , MZ APAS TPE . m & , ) + , )& * TPE - + , E B, ( ;I SC e 4 - - CAPS > - , TPE 0 U . 5 'rq " A * E •;-" . Z ,: ? & 3 ), & M- . Z ,: <# 0 6- 3 * 3C 5 % 5#/ K "D " - n @ C . * 3 =+ .3 & $ T ? .0 >S* -SC . 4 74 ?) % = , €& C . 4 74 = = $ ‘ $ 53 A* ? 3H - c A4 @ & . - =-7& % - -7 . - D =- 1 O )," _ JU D D 4 . - = 3e1 .€ 53A * 5 " B n =- 1 $ T ? 0 >S* -* S1 ,- TPE ! %3> %3 A V- & Rh =-7 S* J -A& ! - ? =- N & O % D $ T ? .0 S U @$ t T & 3 " H: & 9. 53 )," @ ,> % A * ? -O 3H .=- 1 1 - Antiphospholipid Antibody syndrome (APAS) 2 - Catastrophic APAS (CAPS)
  • 121. TPE -* _ & d .E . iS U i " ) d, S A ! " TPE n TPE B i . & B n 53J- S C iS U 'q 6 . @>? U @$ k - J %=- 1 5 'rz 3 M* S>? , .!Z c tA - k 74 , - 53 )," ) , - 6- .=- - S*4&T ‘& $ 3e1 =- [ . TPE x O )& * , -* A )& * , . 0 ABO y T , 0 $ - e7 S %, - 1 $ T ? .0 >S* 3>J k - J - -7 . 9 & 3 S C %, - @>? ), -* @ TPE ) I4 % L Tu ., - 5 -* S1 Substance @ " wf1 . 5 '{X ," B n Q =- - S*4&T - = E ‘ $ %‰1 €& ," B S B n % N * 5 '{' 3 )," ) ;. Substance B A , - 5 '{( 3 , - @ C B n 9- % L Tu $ T ? .0 >S* 3 = $ , SI & ) $ T ? .0 >S* Z @ " ' 8-H $ - .0 S = . * $ T ? 0 >S* , - € f N * 5 " t T + * Š-. &, & 8$ &, &, - € f -$ -* S1 3e1 , - @>? N = TPE 5, A -$ €& 5 '{D 3 ) ) . - R & . 3 A + 4 … x 3e1 , - c N )," , - hC U ` A n , ABO y T , 0 $ Solid hC , - .* % E * w #$ ! " N * 5 * w 1 4 3SC = SI & 3 )," ), -* %, - @>? TPE B n c ABO p H7 * ,> ) n 5 '{2 %'{r 3 ) ) . $ R Y >7 I J A )& * , -* O )& * , . 0 ABO a- $ , 0 $ hC , - 4 %, - B n , . 'WD Q 4 ? . * N * %,. 9 TA , - hC , - 0 > , )," @Z B .3- 7! H" .=- - S*4&T !> - -7 . ( & W S? , - SI A J .3- 7 = ! )," n T-7 . 53 )," ), 3 =+ ! " = 53 ^ Y >J )," , - ,-/ 7 3A ;nU " ), ,> 5 '{{ %'{} " … x * T ? .0 >S* 0 Z ) . TPE ! ,U , ," T-7 . 5 " 3 t T 3>J -7 3 & Z n > , 3 3>J - T- - 74 ;. IVIG& )," B n Protein A – Silica & TPE €& & . 4 ,1 ;. . %) > 8? ), 4 3 , R Š-. N * %3 A* ?) 5 '{qW'}( 3 w L = e % * e t T 1 - Peripheral Blood Stem Cell 2 - Passenger Lymphocyte
  • 122. $ $ +9 / = "G b 4 - SI 5," .3 & -O - - ITP 5, " 3 MI ( V, a/ b, b/ X, b/ a) -j & +-S* . k 4 + -SC IgG U% ITP 5 " ), Evans B , B* - - -7 . 4 ) . . * ITP SI ^ J* T 5, >e &, 8 " &,H L $ & ) SI & , 9&A &, Y , % , * > ) & & HIV & SLE s > ;. ITP ->" B , 5& 9- - =T BA3 5 'D' %'}D ,. € * 1 .3 SI n 4 53 T $ e %ITP e F,. T $ w 1 %, J. ^ - . 3-7 A &) 1 Y >J ITP - $ % .,-/& +- 5 " @x U T- ," 0 .3 , x , T- 2b - J &A 5 '}D , . @-+M ITP _ IVIG& + S] 5 '}2 B& Z = T ITP =- [ . 5 '}r ," / 'z}X 6. T- 43-ZA € T* , N ITP TPE )," € T* %, A * ? TPE 3H - + S] T- . h ITP TPE 9L - Q & t-? 4 d 7 8 1& B,C 1 7& '}{ 3 5 " ) d, , 3 )," € T* S8 .o Protein A–Silica ) %'}q 3A + HIV &, = T ITP > - ., & HIV 3 C J & ITP ,: 4 9. ;J- + 53 KLM - = A =-j & +S C ;J- + 5 '}} T- Z U o , E @ H -I 3 N;.Protein A–Silica %;J- + KLM ;I SC 5 " ), T- . (rX A* + % , . SI B& Z = T ITP wL C Protein A wf1 €& - + , %AABB & ASFA , Z>Q _ 5 '}z " 5 '% ( -* ? )& * ITP 3e1 S-A 1 - Immune Thrombocytopenic Purpura(ITP)
  • 123. TPE < +/- # 0 M "I 5 " n T ? .0 >S* -SC B * .=- - S*4 . 4 ! AIHA . Y H-1 , J. I /i . k 4 -SC IgM . 4 SI .=- - S*4 - CAD C 3H S] 68 & ?& C @$ T-7 . B , & , 0 P =- ( 5, n =- - S*4 - j - j ," &3 C o % k7 .=- - S*4 5 " n 3- S jS & - + " ), 3 C & ) . Y^ .=- - S*4 ,x 53 ) . J & & 0 i - _& & @ & & .3 C & C 5 " 3A B& " ,7 & -7 S*& %B 7 %CLL N . -$, - 1& Rh null e7 S & k 4 -SC & ) IgG b SI B * .=- - S*4 ?& C ‘ $ T-7 . B , Y >7 I & A 0 P e , .=- - S*4 = 5, J. % , 5, n DB * - - -7 . 4 WAHA C 3H .3 C ) . , 7& , " n $ " 6- Y B * .=- - S*4 ; J- . -$, _ 7 # PL - . - % . [ Y^ & & 5 'qX %'q' " ), & @- & .=-S- @ # $ .& & CLL # PL 4 ,-7 e F,. , 5, - SI - = & IVIG % .,-/& +- 5 " B n & . & )," _ JU .0 S L 9. 3J+" d x 3 =+ i .& & , O WAHA SI + S] 3-ZA CAD f .€& 5, -* ? ) % .€& = 5, J. ) . CAD &WAHA )& * & . $€ * 1 4 9. 3e1 TPE Y >7 I CAD IgM . 4 53 )," ) %, " 1 3J+" 0& , . Y >J , TPE ! e4 ,1 = 5, .0 S J 0 P & , J. ?& C @$ @ . _ % " A : & 0& , . = 5," O M- WAHA 5 " CAD $ t T - & 4 - 9. n ), 4 1 - Autoimmune Hemolytic Anemia(AIHA) 2 - Cold Agglutinin Disease 3 - WAHA: warm antibody hemolytic anemia
  • 124. = TPE = %, @P T ? .0 >S* & ) IgG b % 1 . 4 5 '(r %'q( , E ,- % - 3J+" , x PL %, J. WAHA , ," B A > - ^ TPE & ;nU 'W'|r ^ 5, " A* + ), w .& S- AABB & ASFA , Z>Q _ 5 ''z " ) 2W{ 1 - & ' 5 ' %( -* ? )& * TPE - + , E CAHA - ," , ," T-7 . N =- - S*4 ) . - -7 . 4 c A a- L & S & - & ; C & - & 4 ; C 8 - . 5 " 3 C 9. GC -O @ C @>? & 'W( Q ;- ) 4 U 1@ C - & ,. 5 'qD %'q2 3" ,. $ <(RBC ]- 0 K +/ K # K "O D 7& 5, J. L Tu d^ $ RBC K7 $ @ + ,ZA 4& - 4 4 , L Tu 5 " - - 7 +- 4 GC B& & - GC & -J .& -" % " @->? S C! $ .0 S e 0 > ," 3- ]. _& & O 3 =+ L Tu e 5 " n @+- S , .& 3 C ) . T ? .0 >S* K7 $ 4 5 'qr %'q{ , 3A M- - 4 43 5 9Z ` A 37 U n ; J- ,. M ,. " 53 )," ), B19 _& && -J - T .3- 7 =- [ . & ) M .3- 7 4 O %d ,. M A& &A .= .3- 7 = 5 'q} %'qq 3 )," 3A L Tu r 2 - .0 S .y 7 4 & ,1 0 S ," e ?& . ), & + 5, ‰" %, " 3A 3M 4 ‰1 L Tu - k 74 , - % ,. _ d x % -J - .& % .,-/& +- @ i @ C %3 - 4 5 'q} %'qz , J. O % h ;. 3- - ,: =-7 S* & = ] S+- %3M !-H 4 Y^ U A 1& - , = 5 'zX 3 ),- d >O 3 L Tu Q 9- .0 S ," , e 1 - CAHA: cold antibody hemolytic anemia 2 - Aplastic Anemia and Pure Red Blood cell Aplasia 3 - Pure red blood cell aplasia 4 - Tumor necrosis factor- 5 - Progenitor cell
  • 125. TPE e A - = R & ;. A TPE Z8 S-7 d ,. M T- 43-ZA %, )," > k7 ., 4 A @-7, - & 3" 1& e 4 B n %TPE )," € T* 6 . %T ? .0 >S* K7 $ 4 53 ) 53 ) B e 3-7 A - - .o d ?& . * & - 3- :& 3A M- wL 7& %3J- d^ $ = Š-. -7& TPE N * %= e . A e 4 )g , ) , o R . 3 - T ? .0 >S* K7 $ 4& - 4 4 AABB & ASFA , Z>Q _ 5 'D' , 5 '% ( , -* ? )& * TPE - + , E & .
  • 126. AABB ASFA 95* =S T 5 # $% 8U "I ) ; &# 9 A % # 0 $ 5 $% Disease AABB category ASFA Category ABO-incompatible marrow transplant II II Aplastic anemia III III Autoimmune hemolytic anemia III III Coagulation factor inhibitors II II Cryoglobulinemia II II HELLP syndrome (postpartum) NR* NR* Hemolytic-uremic syndrome III III Hyperviscosity/multiple myeloma II II Immune thrombocytopenia purpura II II Platelet alloimmunization III III Post-transfusion purpura I I Pure red cell aplasia III III Red cell alloimmunization III III Thrombotic thrombocytopenic purpura I I * Disorder not ranked by either AABB or ASFA. This disorder is ranked only in context of staphylococcal protein A Immunoadsorption. AABB = American Association of Blood Banks; ASFA= American Society For Apheresis; Category I = Standard acceptable therapy; Category II = sufficient evidence to suggest efficacy usually as adjunctive therapy; Category III = inconclusive evidence of efficacy or uncertain risk/benefit ratio; Category IV = lack of efficacy in controlled trials; HELLP = Hemolysis, elevated liver enzymes, and low platelet.
  • 127. TPE +, - . /0 # 9 - 5 37 " =-M f 3M* 8 2 °c ; , J. .=-j & % .=-7 S* & A& +7 - d M 4 & , J. .=-7 S* & U M- . d 5, " 5 'z' 3 ) M =-7 S* )& * D - J+-A - IgG IgM b 0 S =-7 S* 6 * @ " .=-7 S* I b - -7& 7 d^ $ & B& " ,7 & -7 S* %@]- 7 B S- SI e 5, J. n 3 =+ & rXX mg/dl 9- 3 ^ Y SI =-7 S* ,Z 5, " 3A 5 " N `& C ,J O .e & + ( = A Y^ 7& 5," 0 S S &0 S .=-7 S* @ " .=-7 S* II b D c+S] IgM @P 0 S S IgG & +-7 U IgG ,: 3-7 A IgM =+ , " H B, 3-7 + & n > -]- 8 e 5," 5, " > T- , 4 , , c+S] n 0 >, - ;-$& MU d . E 3 ˆ •2X 4 b -" & ) C 3- ]. = T 3 C s > II b -J 5," IgM ,7 . -$, & - d^ $ ) . h & 'z( , ) & ) IgG ,: IgM SI ," 0 S S .=-7 S* @ " .=-7 S* III b & B 3- ]. @ U .3 C 3 =+ e 5 * @P IgG .c+S] -7 d . E 5, " n e7 =T & - .3- :& , ," ,-/ & 3 4 w t Q .=-7 S* S 8 5 " ), B - 3 T-N M , * ?& C ,J @x U ; C n > %.e 3 , % ; U 5 'z' %'zD %'z2 %@x % x P $ -I - J- ; C %c 7 @ ? @ " -7 d . E - = 5, " $ S] 9. & 8-H & % 7 i S] ]. % 7 5 M- b -" Low–grade) =-+N . B 7 b -" - II b " ), K-LM - •(X -S -* w &U 7 @$ . > & <@ " A x P $ . A - = 5 M- S- .‹ 7 IgM M w % ‹ + & +- .=-7 S* 1 - Cryoglobulinemia 2 - Raynaud phenomenon 3 - IgM > ) -n
  • 128. ' ‹ + & +- Mi # $ 0 -S &, 3H d & c SA ‹ + & +- 5 " ), % & +7 =- - !ZA & , 3 C &, S] 9. & -j & % N . - 5 'zr %'z{ " ), -& B , & -S U . * 5, 9 TA ,Z %=-7 S* 3ESI 9 TA 5 i J =-7 S* 3ESI =-7 S* w 9. 3 =+ - $ n- 5 'z} , 9 TA %, w =-j & 4 5, " 3 C %,. & $ ‘ $ !-H .B , e [ 4 -E l, 3 =+ % Q ; C & =-7 S* ,Z % - 0 $ 1& d x 9. %C 3- ]. _& & 3 C &A & S- -" 0 -7& 0 $ 3 =+ 7&T- %s SL -7 S* 6 O & - , 5, ( % 7&T- B& Z , ," ; C - Y^ U T- -+74 & ," ,- ; C a- L 5 'z2 , J. ,- 9. & ) 9. =-7 S* ,Z % . ) B,C d x U TPE L & ^ 6 T. 'zq %'zz " ; C 0 n ,. Ž w 4 d . E , ," . e +J - , TPE 5 &,H 4 %€& = ? ; C, TPE - = 5 " b& " Y %, 3-7 + & MU 3 =+ ;. ,S1 3-7 + & 6 - = T .;$ - 5, 0 & , ," 5 (XX %(X' , > TPE V 53 . (WD . (WD ;nU 'W'|r @ " Y^ w -iM- , 3 =-7 0 & •r =- >74 •r =- >74 Ti 1 5 (X(%D2 " B * € * .=-7 S* = Ti 1 V - 7& ," _ V- & 8 N * , 1& . - + .=-7 S* L 8 Cryofiltration S& . A x 5, FfU & ), @? ,U & - + , A $ 8 - . 5, 3" € * 5 (XD t T Y ,n ->Q -I .=-j & ‘& $ & w 5 " =-- - o &; C 1 + d A & d, 0 Q %d," $ .), B * 0 U %, w ` 3 =+ .=-j & = n4 T- - $ 5, d & : c A )i w -* S1 1 - Finger print 2 - Alkylating agents
  • 129. TPE 1 D} TPE 3 =+ ,. Ž ^ w &3 e 4 =-7 S* 5 'z} " w n -* S1 ^ U & i- ,x --u & 3 ),M C x$ w ,x ,Z c A 3 3-7 U " ) _,U 5 , -7 3-7 A s> c A , Cryocrit , , w .=-7 S* U 1 9. T- D} c .=-7 S* tA c A 5 3- . -7 % M- 5," o e K$ " 5 * 4 9 TA d x =- - 9. & d : V FfU n , 5 (X2 , & =- d, ) & ; C %~ C AABB & ASFA , Z>Q _ - +, E -7 S* 5 ' %( ? )& * <) * VJ L % 5#/ K $ 5& ^ % 7 8$ 9 1 ( Y 3 7& S* -7 p H7 3 - - GPS [ *B, 0 'qWDr =- & 0 $ = 5 " KLM T $ & ( RPGN ), & M- D & .0& S* -J 0 . @-+M % ‹ + & +- -S J - 53 V " 0 -S &, w 8$ d - & +7 ‹ + & +- & c SA ‹ + & +- •zr 5,. M e M 0 -S &, w d 3 =+ ;. J - 5,. M 2 & GBM ,: -S 0& S* 6 MI ,: € * . 4 B, = % @ C IV – k -SC xP $ 8 . 4 = 3 s> % (Xr & " n J )i - 4 O 3 =+ & 3 ? 4 = 5 (X{ , &) 3 C Y >7 I B , = 5 " n - -" C 6S U c GPS Y >7 I , & ) 3A M- ?& & V B,C d x %3 ) . -S & T $ 5 (X} , dA T $~ C & O • rX &,U - & -& -I ,U -j & % -S U Y >J d x [ * -S d . E 5," 7 *& T ? 0 >S* , S- & WBC %RBC - w 1 - Goodpasture syndrome 2 - Rapidly Progressive Glomerulonephritis 3 - Crescent formation 4 - Glomerular Basement Membrane
  • 130. T $ 3SC =.4 > ) . Y^ $ !S$ @ "4% - d .E CO2 M 3-S ? 9 TA % - J ? A * 7 - S- %3 ^Q 5 (Xq ," 7 / 74 @$ =- S* . 1& 3SC 5 (Xz %('X 3 ,- JA S+- & &T- ^ ƒ ) . TPE %GPS ," -x 9. TPE & w e 7 VA & 4 ,-7 w i .& ^ .ƒ 53 A - 4 3A M- , @? ,U 3e1 MI ,: 4…8 V •r =- >74 Ti 1 & }W'2 d, & 8 ;nU 'W'|r @ " 5 ''z ," -7 >e n- & 4 ,Z 9. n % i .& T . . . 1 7& " ) = Ti 1 V C • r =- >74 Y >7 I 5 " 3e1 . . = Ti 1 V ML FFP Z T n %) & ”? 7* J& T $ ," , w 1 & Z . A Ti 1 FFP -7 'W( % " T $ & -S J - Y -$ - * # PL 5, E ?C 5 "T n , A e =- >74 J? n , & 4 - _ & )," Y ,n % . (WD ; k e , - & .,-/& +- ) ., c A 5 " -*;- P c A $ !S$ 1& -S / 8$ & ," ), M , [ *B, n 4 5," ,- JA S+- 5 " -x 1 e ; k f7 ) . , ) DW2 - SI 5, ) { W'( Y^ - 4 n 4 5 (''% ('( " ) 3 = - 4 ,- JA S+- 3 ˆ B ^ 53J- 0& , ) { ^Q . f7 3 ? MI ,: A& 4 & + n c -S +S C 3M* % " b& " & N . , 53 @ H -I -S & .0& S* < "T n . - , ,- JA S+- & &T- ) .c A -S - hU & d," 1 &, % T $ ) . - W -S Ti 1 - rmg/dl 9- =- - -S - W 5, " " , A 0 . 0 +" •DXWrX d," - > - w S8 c A @ " , J. >- ; k ,Z +"T 53 KLM -S J - - 5 " ) - , ," .B A ,- JA S+- 5," &T- )&
  • 131. TPE ML O 0 U , J. $ !S$ ,? A =- [ . & , " J& 4 &) ,- T-7 - 5 ('D %('2 3 ; -J )& * [ *B, TPE B n - +, E AABB & ASFA , Z>Q _ 5 ' %( -* ? <) other RPGNS &: V _Y 6/ ? - 37 1; ' & RPGN c+S] - .B i RPGN b & % [ *B, )& C [ *B, M ‹ + & +- . A %. - = & . 5 1& ( - T $ 3 =+ U - = h 53 D 7 . 0 +" & 7& S* , ," w e 7 @ " & - & +7 ‹ + & +- ! RPGN e.& * =- T 5, " " ;. ) . GPS 8$ F $ ^ * d 8 % " ) c SA ‹ + & +- c+S] - - )& * , J. .c+S] Y^ 0 -S &, w M RPGN - - i )& * d T-N Z ,ZA & RPGN ) .; C & - , -S - 3 =+ )& * . - 5 ('r ,. !S L -7 S* @ %, " " 3 - J- 3-7 + & K-LM i - 2 + & +- 3-/g 4 S & RPGN c+S] - ^ * = ^=/ "WŽ . r T- 3> ANCA - -J %RPGN - - *& 7 * 5 ('{ %('} , J. ,- JA S+- e 4 SI & 7&T- - 6 . V? & 53 M - & = 4 - c+C - = 5, 3A , & @$ $d P T-7 . * # PL 5 ,. $ ,- , ) ,- T-7 - - U GBM 4 { 0 A n > = $_ M B n bioincompatible A& MI A = 5 , , ,M 3-7 + & , M* @-A& ," & ,- d O & 3 )," V? & ) - & . ) J* 8 TPE &3 A + - = ;. Immunoadsorption 53 ) ) . -S +S C >e 53 " TPE M O ), 4 @ . 1 - Immune complex RPGN 2 - Pauci immune RPGN 3 - Crescent formation 4 - Henoch-schönlein purpura 5 - Anti neutrophilic cytoplasmic antibody 6 - Bioincompatible coprophan membrane
  • 132. c A ) M GBM ,: 4 &, - )," 0 6 78 =, N c A -O , i d " T* 0 U e , ,-/& A : O Š-. 7 U +S C >e 0 U 5," , T-7 - , - RPGNS –- - 3 =+ =- [ . TPE 53 ) ^ c A ) T-7 FfU U & -S e M- %, J. - 3A M- N ), w .& ;I SC - 5 " & ) L 3 .c+S] % 4 4 , c A d x . 'W'|r & Y TPE ^ 5, 3" S] & k >-A @ e7 . 8 & •r =- >74 & =-7 = Ti 1 V & , - & , & )," I4 ;nU 5 ''z %'rq ," 3 e 4 GBM ,: 4 RPGN AABB & ASFA , Z>Q t>Q 5 ' %( , -* ? )& * TPE B n - + , E < #3B? MN $ 1! - = V " RA 5," V " 3 $ " k7- - RA ,-/ & A RF % - SI 5," n @SC + & @P e7 =T -J A= n4 >7 53 IgG -SC IgM b 4 , J. % " 3A ;. , , 3 4 i - AQ & " ), - -]- 4 5 ('q ," " 9Z RA c T k Y -Z J , E $ ,-/& +- % NSAIDS ,-/& -I e 7 ,: @ C @ " RA U @ C %, J. > , ," - - 53 SP @$ .,-/& &; ƒ @ , J. ; J- , @ , Y^ U " ) J.4 +S C ,-/ & ,: ), & + A (TNF .), e %d J & & Q d >- % ^ 4 .& . RA TPE 5 ('z %((X , A * ? ,- RA ) T- D - PAS ) 78 %3 ) -Z & ,: ), 4 @ d 78 &` A 78 1 5 ((' T- 43-ZA •D( , ) , o d J & _ 5 ((( 3A * ? FDA ,- v - = PAS ) i 1 - Rheumatoid Arthritis,RA 2 - Tumor necrosis factor 3 - PAS=Staphylococcal protein A-silica column
  • 133. TPE C SP ;J- PAS ) ASFA & AABB , Z>Q 5 ' %( -* ? )& * i . ) .& U <+ /N `- "@ `& C ,1 w e 7 n 3 d^ $ .& * S C - J- 3-7 + & ) , _ 4 - 7 + & .B , 5, " A - +J - 4 n- & $ 5, " , Z>Q 'z 0&,1 t>Q % -* `& C ) (@&+ /N `- 95* =S " O Large vessel vasculitis Giant cell ( temporal ) arteritis Takayasu arteritis Medium- sized vessel vasculitis Polyarteritis nodosa Kawasaki syndrome Small vessel vasculitis Wegener granulomatosis Churg – strauss syndrome Microscopic polyangiitis Henoch–Schönlein purpura Essential cryoglobulinemic vasculitis Cutaneous leukocytoclastic angiitis = h .c+S] hU 7& 3 $ " - = k7- SI @-A& ; - ,: . 4 @ .B , . 4 hU & .B , %churg-strauss B , %3 4 S & ((D c-ANCA *& 7 * ANCA 3 =.ˆ % " 3A p-ANCA [ * B , & crescentric glomerulonephritis 5 ((2 F 8 .B , = 0 . . A 37 $ Y >7 I ,- JA S+- 53 -7 + & .B , SI 0& !$ 7&T- = TPE ), 4 @ . 5 ((r " ) &TA % - , ," ) M & ) . TPE + d, ^ Q ,- d O , ,. " % .B ,
  • 134. %, ) , o & ,U - 3 =+ 1& = TPE 53 5 (({ %((} " 3 $ d 78 h 7& )," ) i . ) . TPE %Churg –strauss B , 5 ((q 3 ),M ),. M e .& F P 9- ), A TPE ) -S -* )," 3 O % + & +- 3-/g 4 S & *& 7 * 5, J. T-7 J & .E - Tn , c A 3 =+ , 1& *& 7 * - )& * 0U e <, > - @ C ) .c A <GBM ,: 4 - T . - " [ * - @ " ) - = -k . 4 3" 7 U O 3SC , ," T $ - "( 53 ANCA 5, ,- T-7 - U A Q - "; , " T-7 & , -S - *& - c A = 5 (DX 3 ) O TPE B 3- ]. !> & 3 4 S 5 ((z , TPE - + , E , ," - J- 3-7 + & AABB & ASFA , Z>Q _ b - i . ) . TPE T -J 5 ' %( -* ? )& * ), w . - # PL 5 " A * + %, - , ," d P TPE , = 5 (DX , . o ,- JA S+- & .,-/& @->? =- >74 5 " B n % * 3-> - -7 3- :& - & , & & T $ & Z . A 9. 4 i 5 * ) = Ti 1 V C •r 5 " ) ! "= ," " 1& < aC "D - C =- [ . & , - -* S1 & hC , - .9L TPE 5 , - hC 1 - Solid organ Transplantation
  • 135. TPE <1 %$ , - V %, A ` 7S 8 & 3A * 74 ., - SI + ;I SC ABO . k 4 -SC . 4 @>? - 3 =+ 4 68 & U ` A , - =- N " 3A p H7 5,. & %, J. , - hC & 1 HLA & " KLM N $ .y S-A& … M & 0 -S &, - 4 %= >-A w % ` A, - %TPE S 1 & . 6 . 53 - +J Y , C , - hC ;-M - 4 5 (D' , ) ) e- U -iM- w @ " -S & ,> ., - B n c , 3>? ( rituximab & IVIG % _ -7& , ? .& = ] S+- U & .,-/& +- D d U 5, 3A ;. @- A d^ A +- = - 4 3 =+ S? *, 3A 5," T- ,: 4 d^ PH .,-/& c7 %,. & .& = ;I -SC , - 5 (D( %(DD " & . & Cell 8 'zqX 6. @ & & 'z}X 6. $ & %d " T* , ," B C ,- c TPE 3 ), 4 @ . + ;I SC 5," A * + -S , - ) J* N;. ` A TPE %, ) , M -S , - TPE e1 @ ? 5 (D2W(Dq " € T* A + ;. S? 3A * 74 , - €& = % -S , - TPE ), A 1& %, 3A ;. . TPE )& C - h S8 R & 3 53 ),M B n = )," 0 & t-? Š-. 7& %3 )," € T* B n >S? 3A * 74 - 0 - &, . J - ?& C , - ,- v 3A >S? 6ShC 9L = ) , $ `& C , N 3 @+M % " 0 - %c SA ‹ + & +- €& IgG x P $ w 3> 5 " 7& " 0 Y >J . J - - %, ) em $ N * %3 0 ., - TPE & " " f* P-LM =- N T- & 3 $& 3 e 4 S? +S C 5 (Dz %(2X 3J- _ C = 3 U Z-? d C Q >7 5 ) e4 ) %, )," _ JU HLA . k 4 @>? - , - B n 9- TPE c " ,. 9 & A , Sx U .3- 7 - B 53 )," 1 - Reject 2 - Tacrolimus 3 - Mycophenolate mofetil
  • 136. 3A 0 U @-7 =- . & " _ ,. * cross match TPE ! 4 ,1 ) . i @ C w 5 1& , - ' & * cross match0 PU "& % & –A =-j & ) wf1 €& = - € T* = , N _ 53 )," A * U`A, - -* S1 5 (2'W(22 , " S8 Y Z %, 3A -S , - c] & , )," ) 4 €& $ —J- ABO p H7 * .,> & . -S T- 43-ZA ., - e M .@+ & , * TPE ,. M ), 4 3 , R = ;e % x $ 8 5 (2rW(2} 3 , - 9- 4 ,1 %= 1& 53J- O %, )," 3-> -S 3A * 74 ., - )g ,., , - B n 1 %, J. B ^ ! " ,1 & d e1 ., , , .9 & A = , HLA k 4 & -SC ^ - . 4 . 4 ( 5 " e , VQ Z <; $ 5% C 2 5 " -S &c & n 3 0 Q - 0 A c & + 7& S* 9Z + 6M , A ` Y — ,n % -S 3A * 74 , - - •DX FGS 7 S- DXWrX A 3 M ,. " ," 4 Tk 0 . A Protein 5 (2q %(2z ,. 9 TA 0& S* f ˆ & " , A =-j & 1& h U ,. 9. =-j & ‰" KLM 8 , c A & adsorption 5, n @ >e 8$ - 53 )," -x ,- JA S+- ) . c A ) %. [ )," -x 1 - -* S1 , - @>? = ] S+- )& c A T n 53 n )," , - . S? . * 3A * 74 7+ &B & `& C M - 3 A * 74 , - *, 3A - &y &~ C n @ C + & " , - =T & ,-]-7 ] . 3 =+ 7 J = 53 ), ), 0 9- ,- =-j & ]-7 B& , d^ $ , - - , LDL L 9. 5," !> 1 - Protein A-sepharose immunoadsorption 2 - Cross reaction 3 - Recurrence of Disease 4 - FGS=Focal glomerulosclerosis
  • 137. TPE )," A* + % - = , - -SC T C ;. 'c A A 5 (rX 3 ) 5 (r' 3 ASFA 95* =S T 5 # $% 8U "(b ) @I&%$ + - 5 / '+ , - $' 3 $ 5 $% AABB Disease ASFA/AABB Category Renal disorder Glomerular basement membrane antibody disease I Rapidly progressive glomerulonephritis II Hemolytic-uremic syndrome III Recurrent focal and segmental glomerulosclerosis III Lupus nephritis IV Rheumatic Disorders Systemic vasculitis III Scleroderma / progressive systemic sclerosis III Systemic lupus erythematosus NR Antiphospholipid antibody syndrome NR Rheumatoid arthritis IV Metabolic Disorder Acute Hepatic failure III Overdose / poisoning III Solid Organ Transplantation Presensitization to donor organ III Transplantation across ABO barrier III Humoral solid organ rejection III Renal allograft rejection (cellular) IV ASFA/AABB assigned specifically to heart transplant rejection. NR = not ranked. +N +- 5/ . /0 % 1 4 -I ,1 e 4 3 .3- :& @ " 9L = 5," 1 p H7 1 - Photopheresis
  • 138. < # - /N3 F 1 ( 0& JS %LDL 6 A 9 TA Y , ," ,Z 3 O 0 $ S- A 7& JS ] . 0& JS d %d i . b 5 " KLM LPa a =-j & ]-7 & 650 -1000mg/dl " y & " n C 0& 6. 0 $ % & `& C & 4 & T* @+" 0& JS %LDL ,Z ;. d i & . b 53 V " i7 (X @>? - _ `& C c & S+ & 4 & i7 (X = T* %, A 9 TA LP a & 350-500 mg/dl ‰8 1 LDL . ] +- k > 5 " n 3 =+ i7 DX = & 1 ->Q ,-A & .0 S @$ LDL 0& JS 6-SL - = 0S 5 '(r " 0& JS & LDL 9 TA n & ) @$ , LDL T ;-E & " @, fI ; k d --u ! , 7& JS ] . a- $ 0 +" D ,- ), " , .= % & HMG –COA .), e @->? .& =, N 5, . o - - +- ,- & & x J &) -:o .€& = d i & . . FH h & d i . FH r 2 @ & & =-J jS @ " FH B& !$ .& 5, ?_ & y ^ 3 L–Arginine T n 3 t-ZH 0 U n d P d -U i 53 T* n V ) = d 7 8 5 " @ ,> - ,-J ,-J - ! 5,. 9. & S+ & 4 & )," } { 3 =+ ,> , - & 0 & 3 " % B jS c , A3? Q U 1 . ,1 % i 5 " e M- - = % & `& C - ,. " 1& d x q c A4 5 " B n c A4 .€& b ! , 4 J & LDL-C + + T-A L .€& $ € * LDL-C 3" LDL J = ]. %LDL . 4 @ " affinity . 53 affinity A * & , . - (' 0&,1 5, ‘ $ LP a @ " B 4 & U .=-j & ]-7 . d 7 5,. M , -* ? LDL c A4 3H - 1 - Hypercholestrolemia 2 - Familial Hypercholestrolemia 3 - Hydroxy-methlglutaryl coenzyme A Reductase 4 - Bleomycin 5 - Probucol 6 - Ileum Bypass 7 - Portacaval Shunt 8 - LDL-Cholestrol
  • 139. TPE & ) 9. M- •rX LDL-C Z % ;nU TPE 3 " & `& C d & ,S1 T* @-SH GC , . 'W( . d, HDL 9. > 0 U =-C % ‘ $ LPa ;. & LDL ;. TPE 5 (rDW(r{ 3e1 .€ %w S8 O = VA 5 " T- %3 k& 4 4 ,- +S C , * c] & c A4 €& ! - LDL L - & on–line ,1 53 A *d x% - A 9. LDL )(@(&# - /N3 F $% LDL K :% ?/ $ Y "( • Homozygotes with an LDL cholesterol 500mg/dl • Heterozygotes with an LDL cholesterol 300mg/dl* • Heterozygotes with an LDL cholesterol 200mg/dl and documented coronary artery disease* * for heterozygotes, a 6-month trial of maximal drug therapy in combination with an American Heart Association Step II diet is to be tried before initiating therapy. LDL L wf1 3 J? 3 )," U Q F,. = =- ; J- = , N J ; J- e 7& %, ,1 LDL O 8 .; J- = 5, A * ? GH N * 5 D2 %(r} 3 _ ),H d^ & ) FDA ,- HELP & d 7 HDL ,Z TPE J Z %LDL ,Z E 9. d 7 J ; J- d x ; J- = ) ,. M d 7 8 = 5,. 9. T- k >-A 9. 4 )& C & (rq •rD T- 0& JS 9. > ;nU -I Š-. ; J- = 7& 5 (rz * •r T- HDL & •D{ & ;E 8 , , , $ ; J- = T % n- 5 , 7& JS ]-. , .€& = b& " 5," A x &Z P ? p H7 , + 4 - , &,H %, J. B& Z & & fu .€& 3>J FH > - 4 c A4 - + , E 0 -S- A 7& JS ]-. AABB• & ASFA , Z>Q _ 5 * 5 '%( -* ? I )& * LDL 8N$ $ 5 1( A ; T4 @-/ -A ; T 4 > @-7, 3 7I 0 & 0 $ %B JA - ' ( 5 * n % " fI ,-]-7 1 - -A ,- Tn > -J & ,-. 1 - Refsum Disease (heredopathia atactica polyneuritiformis) 2 - Phytanoyl-CoA hydroxylase
  • 140. fI ; k ! - -A ,- V n n- C *, B 6. Q SI ; C & [L J 4 % 8-H & 5 " n .3A N $ˆ & .=-j & ]-7 ( %c - + % % ,ZA - 4 5, " 3A Y> Z i- 3- - =+ 7& 4 3A M- 0 37 U 5,. & 3 =+ ;. 4 & -S U & " f* 3 $& & B 4 - = % - -A ,- 1 @ ? 9 TA 0 > , 3 5 ({X%({' * e* y n 3" * % >7 .) &4 A t Q - -A ,- 3A 3 ;e - = _ & K-LM & ) @-+M _ fI ; k 5 " % fI ; k 1 -U . N & %; C n , >e & B 4 - ,““-J W i ! d -A $ˆ n , J , fI ; k 1& = 5 " n - SI %0 - w PC +S C 0 $ …8 U 8 , k&, N V ,U 9- ;J-7 N " ’ U 3 ,U = 3" 3? , 5 " -7 ; C , ,M GC & ) 9 TA - -A ,- 5,. Ž ;. e* - & & 9. 0 > , % fI ; k 0 b& " )& C , 3- :& K Z & i- 3- - - = ; C >e > TPE & fI ; k … x Y >7 I 5 '(r " " & % - K Z 0 - w PC ,- … 8 U 9 TA & k&, . N V ;J-7 " ; C , ,M & -J 9 & =$ f + & - -A ,- $ˆ 9. =- N;. TPE 5 & + - -A ; C V >e > fI ; k & TPE b n 5 fI ; k 3 &,H 9. d^ Z d " T* _ , 1& d^ Z )," 0 78 N * 5 " = Ti 1 V •r =- >74 ) . DW{ . . ;nU & TPE 3 =+ %B - -A ,- ,Z -7& 9. , 5 ({X%({( " -x n4 3 ˆ B ^ 5 ({D , B& , 0 ,U - -A ,- ’ U . (W2 @x A -J … 8 - )g LDL A4 %, 1 $ .=-j & ]-7 - -A ,- ’ U > Y : & ," O %, )," T- ; C , ,M N 4& d -A ^ 5 ({2 " T- =-7 S* 1 - Phytanic acid 2 - Retinitis Pigmentosa
  • 141. TPE ` N $ % 4 d 5 c% 1; @ C ,U 9- ƒ , C -I , C 6e1 O 3 =+ -J d O . $ .€& 5 " n F Q !-H 1 h @ C e1 M k7 A , )i . -J ‘ $ 3e1 € @ "&) M ?& b & ! $ -J ;-Z J ‘ $ % -S VA 9 TA %), k &^ t Q 3 )& -$ d x 5," TPE & 0 " . t Q Y k -A . %T-7 . 9- - SI 5 " ) ;. e 4 T n 3 =+ % x P $ . 4=" 5 ({r -* ? 3H €& €& = 53 A + 3- J & .& ,U 9- ƒ F P - , TPE ), 4 1 3- J & ") . M ;nU & " ^ Q C 6 - % ({{ , " @P .=-j & L d -x P$ = .& S 1 53 )," € T* O %, ?& C 9L &,H M- 5 '(r ) " 2=- c- & D=- J = & %( - @- , N * %3 A + ;. k&T* k&, , ," ,-/& - ]-. =- N;. TPE = , N TPE 5 " &,H A .=-j & =-J & - WL V- & 0 P @-7, 9 O r M . 7& 3 )," V? & ) ;. ,-/ 7 A - 4 ˜ ? $ " 3- J 5 '(r " $ 1 - 4 =-J M- Z J n 3 ) ,U 9- F P TPE - + , ASFA & AABB , Z>Q _ S Q -O 3H Y , ," - TPE B n e M- 5 '%( ," III )& * .3- J & .& )," $ " @ C $ ^ …8 & )," V? & 3- J & & ,U 9- ƒ ƒ TPE 0 U =-C 5, E Z8 %, J. .=-j & ," , p H7 O ,? A & &,H O %, " @P .,-]-7 & A .=-j & .& ,U 9- < @ " .& = %," %=-J i %=-/ A %=- - % .=- &T % ZSU . * JA ,: %B - - 74 % e - ) & .& 5," 0 7 & & =-J % 7&T- % &T- %=-J g 53 ), 4 (( ) " 0&,1 ) T- 43-ZA e 4 TPE 1 - Drug Overdose & Poisoning 2 - Methyl parathion 3 - Vincristine 4 - Cisplatin 5 - Amanita phalloides
  • 142. ) @I&` :% 5 K` 6 K $% TPE :% ?/ * # $ % "(( Medication Pb (%) Vd (L/Kg) Metabolism Excretion Digitoxin 30 6-7 Stomach Urine Cisplatin 90 0.3 Liver Urine Vincristine 75 7.2 Liver feces Verapamil* 90 4.5-7 Liver Urine Thyroxin* 99 ND Liver feces Antithymocyte NA 0.12 Liver/Spleen NA globulin Phenprocoumon 99 0.14-0.17 Liver Urine (coumadin deriviate) Phenytoin 90-95 0.6-0.7 Liver Bile/ Urine Paraquest 0 1.2-1.6 Liver Urine Methylparation >90 10 Liver Urine/ feces Sodium cholorate NA ND Kidney Urine Amantia Low ND NA NA (mushroom) Ethylene glycole ? 0.83 Liver Urine * Reports describing failure of plasma exchange were also published. Pb= protein binding; Vd = Volume of distribution; NA = not applicable; ND = not determined.
  • 143. TPE = % 4# $ |! @SC = e =A - ,U 9- ƒ & B 3- ]. 3 0 $ %,> U % JS & - % & .9 & )," … 8 @SC i 5, J. 4 , &4 1 @x U ,> U 5 ) " .=-J C & iS U U w N ,> % ?& C . 7 4 & % -S % 7* % @ " +- S ; C 53 T K Z & -7 0 B,C J Z ^Q C Z •{XWqX n 3 L ,> , - 53 7 J ~ C " ), M d .E -J 5 " , - &, - - & y •{X 9- 5, J. Tu B fu .@ + & 3-7& +7 %V 53 UY - = S 8 )& . - - 4 )& - T-S 5 " -x -7 . 7 4… x .), . 9 TA 5 " -x %) & & +- SA @x U B - 4 d^ PH , @? ,U Z 3- :& >e 3e1 3 & d^ PH & - .3 U E $ MA 3- :& - ? & - - & ] . % .=+J % - . - 5, " T n 5 ({}W({z , " ) n 1 @$ MA 9. i .% =+ -J .3-7 ‘& $ % -7 . 3A Ti 1 TPE 0 U =-C Z . A @ .=-j & > =- & , " Tu B @ C 3 N JS & - 53 )," V? & 1 % ?& C @$ ;nU 9 TA B,C TPE 7& )," ) - S-A . & ? x T-7 %T-7 . N * %, J. ,> ), M 3" 5 " ‘ $ . d, c Y >J Z 3-H1 FFP Ti 1 5, JS1 . B * S- '( , 7& iJ 4 3ESI c K7 $ , A V n l - 4 @ .=-J ‘ $ ), M ,> < ) .€& b 0 A= 7 +- & .= 9" t Q k -A ." $ "( Sorbent . t Q k -A c A "; =- >74 T-7 V &, ^ fˆ T-7 . "! 0 "@ " . MI T-7 "@ 1 - Acute Hepatic Failure
  • 144. $" $ 8 /3 "D - ,x & * C 0 Q 9 TA > )," 3 O 8 % .€& = B , Š-. , “-* ? ,> , - 3H , ,U & ,> +S C S>? ‰8 L $ >e - = # PL 3 3 ^ * 4 - . = + 5,. 9 T“A 5, Z d^ $ &, % $ MA & k 7& 3- :& .3A M- n TPE B n d 7 8 ) ' 53 )," n 1 @$ MA ICP 9. 3-S ? ,> U > - 9. %, ," TPE Z7 d +M + 5," c A ; J- 1 & )," t T 1 d - - T-7 =+ " , " 3>J --u & )T- ;-JS > n d - V n & 7* &,U , TPE N * = 5, @$ , e - ]. - k 3 - 6n- & =j 8 & w S8 O 0 PU , … x - = T K Z 53 @+M 7$ . >-A 0 U hA l $ ,> .0 S -J ] %Bioartificial ,> B- 4 ,1 3e1 & )," ,1 c A4 ) i ! - 53 S-A E H $ e - ]. Metabolic contact -7 6e1 c] & "f* 0 " )," B n = 78 5 " " f* % 7 $ . >-A 0 $ = A 1Bi . 3C {Wq d, - n 1 @$ MA ICP & B - 4 ‰8 9. %3 S 7T ), &,- & , ,1 3A M- = 53 ) M , )," S- & = & 5," ,> , - 1 - Intracranial pressure
  • 145. TPE <e5 9 1. Mcleod Bc. Introduction to the third special issue on clinical applications of therapeutic apheresis. J. clin. Apheresis. 2000, 15: 1-5. 2. Smith Jw, Weinstein R, Hillyer KL for the AABB Hemapheresis committee. Therapeutic apheresis: A summary of current indication categories endorsed by the AABB & ASFA. Transfusion. 2003, 43: 820. 3. Ropper AH. The Guillain-Barre syndrome. N Eng J Med. 1992, 326: 1130. 4. Hughes RA, Rees JH. Guillain-Barre syndrome. Curr opin Neurol. 1994, 7: 386. 5. Koski CI, Gratz E, Sutherland J, et al. Clinical correlation with anti-peripheral myelin Abs. in Guillain-Barre syndrome. Ann Neurol. 1968, 19: 573. 6. Vriesendrop FJ, Mishu B, Blaser MJ, Koski CL. Serum antibodies to GM-1, GD16, peripheral nerve myelin, & campylobacter jejuni in patients with Guillain- Barre syndrome & controls. Ann Neurol. 1993, 34: 130. 7. Rees JH, Saudian SE, Gregson NA, Hughes RAC. C.jejuni infection & Guillain- Barre syndrome. N Eng J Med. 1995, 333: 1374. 8. Willison HJ, Kennedy PGE. Gangliosides & bacterial toxins in Guillain-Barre syndrome. J Neuro immunol. 1993, 46: 105. 9. Vandermeche FGA, Schmitz PIM & the Dutch Guillain-Barre study group. A randomized trial comparing IVIG & PE in Guillain-Barre syndrome. N Eng J Med. 1992, 326: 1123. 10. Brill V, Ilse WK, Pearce R, et al. Pilot trial of immunoglobulin versus PE in patients with Guillain-Barre syndrome. Neurology. 1996, 46: 100. 11. Plasma exchange/Sandoglobulin Guillain-Barre syndrome trial group.Randomized trial of PE, IVIG & combined treatments in GBS. Lancet. 1997, 349: 225. 12. Mendell JR, Kissel JT, Kennedy MS, et al. Plasma exchange & prednisolone in
  • 146. Guillain-Barre syndrome. A controled randomized trial. Neurology. 1985, 35: 1551. 13. Ropper AE, Albert JW, Addison R. Limited relapses in Guillain-Barre syndrome after plasma exchange. Arch Neurol. 1988, 45: 314. 14. Hughes RA, Wijdicks EF, Barchu R, Beuso E. Practice parameter: Immunotherapy for GBS: report of the quality standards subcommittee of the American. Neurology. 2003, sep.23:61(6): 736. 15. Cornblath DR, Asbury AK, Albers JW, etal. Research criteria for diagnosis of chronic inflammatory demyelinating polyneuropathy ( CIPD ). Report from an ad Hoc subcommittee of the American Academy of neurology AIDS task force. Neurology. 1991, 41: 617. 16. Dyck PJ, Dauibe J, O'Brien P, et al. Plasma exchange in CIPD. Myoclinic proc. 1975, 50: 621. 17. Jeffrey LW, Alvaro AP. Haemapheresis. in Henry JB, Clinical Diagnosis & Management by Labratory Methods. 20th ed.WB Saunders, 2001:791. 18. Simon IL, Annunziata P, Maimone D, et al. Serum & CSF anti-GM1 antibodies in patients with GBS & CIPD. J Neuro Sci. 1993, 114: 49. 19. Khalili-shirazi A, Atkinson P, Gregson N, Hughes RAC. Antibody response to p0 & p2 myelin proteins in Guillain-Barre syndrome & CIPD. J Neuro immunol. 1993, 46: 245. 20. Connolly AM, Pestronk A, Trotter JL, et al. High titer selective anti-beta- tubulin antibodies in chronic demyelinating polyneuropathy. Neurology. 1993, 43: 557. 21. Mendell JR. Chronic inflammatory demyelinating polyradiculopathy. Annu Rev Med. 1993, 44: 211. 22. Van Doorn PA, Ruts L. Treatment of chronic inflammatory demyelinating polyneuropathy. Curr opin Neurol. 2004, 17: 607.
  • 147. TPE 23. Hahn AF, Bolton CF, Pillay N, et al. Plasma-exchange therapy in CIPD: A- double-blind, sham-controlled, cross-over study. Brain. 1996, 119: 1055. 24. McLeod Bc. Therapeutic apheresis: A physicians Handbook. 1st ed. Bethesda. AABB press, 2005:76-85. 25. McLeod Bc, Price TH, Weinstein R, eds. Apheresis: Principles & Practice. 2nd ed.Bethesda MD: AABB press. 2003:237. 26. Hopkins LC. Clinical features of MG. Neurol clin North Am. 1994, 12: 243. 27. Maselli RA. Pathophysiology of Myasthenia Gravis & Lambert-Eaton syndrome. Neurol clin. 1994, 12: 285. 28. Vincent A, Rothwell P. Myasthenia Gravis. Autoimmunity. 2004, 37: 317-19. 29. Saunder DB, Scoppeta C. The treatment of patients with MG. Neurol clin. 1994, 12: 343. 30. Meriggiali MN, Gafaloni E, Al-Hayk KA, Rowing J. Neurology. 2003, NOV 25, 61(10): 1438. 31. Gajdas P. Intravenous Immunoglobulin in MG. Clin Exp Immunol. 1994, 97: 49. 32. Genkins G, Sivak M, Tartter PI. Treatment strategies in MG. Ann N Y Acad sci. 1993, 681: 603. 33. Gajdas P, Chevert S, Clair B, et al.for the Myasthenia Gravis clinical study group. Clinical trial of plasma exchange & high-dose intravenous immunoglobulin in MG. Ann Neurol. 1997, 41: 789. 34. Winters JL, Pineda AA. Hemapheresis. In Henry JB(ed): Clinical Diagnosis & Management by laboratory Methods. 20th ed. WB Saunders, 2001:776-805. 35. Dau PC, Lindstrom JM, Cassel CK, et al. Plasmapheresis & Immunosuppressive drug therapy in MG. N Eng J Med. 1977, 297: 1134. 36. Weinstein R. Therapeutic apherersis in neurological disorders. J. clin.
  • 148. Apheresis. 2000, 15: 74. 37. Antozzi C, Gemma M, Regi B, et al. A short plasma exchange protocol is effective in severe MG. J Neurol. 1991, 238: 103. 38. Qureshi AI, Choudhry MA, Akbar MS. Plasma exchange vs. intravenous immunoglobulin treatment in myasthenic crisis. Neurology. 1999, 52: 629. 39. Ichikawa M, Koh CS, Hata Y, et al. Immunoadsorption plasmapheresis for sever genralized MG. Arch.Dis.child. 1993, 69: 236. 40. Benny WB, Sutton DMC, Oger J, et al. Clinical evaluation of a staphylococcal protein A immunoadsorption system in the treatment of MG patients. Transfusion. 1999, 39: 682. 41. Paucuzzi RM. Myasthenia gravis & Lambert-Eaton syndrome. Ther Apheresis. 2002, 6: 57. 42. Saunder DB. Lambert-Eaton Myasthenic syndrome: Diagnosis & Treatment. Ann N Y Acad sci. 2003, 998: 500. 43. Dau PC, Denis EH. Plasmapheresis & Immunosuppressive drug therapy in the Eaton-Lambert syndrome. Ann Neurol. 1982, 11: 570. 44. Senevirante U, de silva R. Lambert-Eaton Myasthenic syndrome. Postgard Med J. 1999, 75: 516. 45. Tim RW, Massey JM, Saunders DB. Lambert-eaton Myasthenic syndrome(LEMS). Clinical & electrodiagnostic features & response to therapy in 59 patients. Ann N Y Acad sci. 1998, 841: 823. 46. Chalk CH, Murray NM, Newsom-Davis J, et al. Response of the Lambert-Eaton Myasthenic syndrome to treatment of associated small-cell lung carcinoma. Neurology. 1990, 40: 1552. 47. Griswold W, Drlicek M. Paraneoplastic neuropathy. Curr opin Neurol. 1999, 12: 617.
  • 149. TPE 48. Moll JWB, Vecht CJ. Immune diagnosis of paraneoplastic neurological disease. Clin Neurol Neurosurge. 1995, 97: 71. 49. McLeod BC. TPE in Neurologic disorders. In McLeod BC, Price TH, Weinstein R, eds.Apheresis: Principles & Practice. 2nd ed. AABB press, Bethesda, 2003:321- 343. 50. Rudick RA, Cohen JA, Weinstock-Guttman B, et al. Management of multiple sclerosis. N Eng J Med. 1997, 337: 1604. 51. Compston A. Genetic epidemiology of multiple sclerosis. J Neurol Neurosurg Psychiatry. 1997, 62: 553. 52. Hafler DA, Weiner HL. Immunologic mechanisms & therapy in MS. Immunol Rev. 1995, 144: 75. 53. Weinshenker BG, Sibley WA. Natural history & treatment of multiple sclerosis. Curr opin Neurol Neurosurg. 1992, 5: 203. 54. Storch MK, Piddlesdens S, Haltia M, et al. Multiple sclerosis: In situ evidence for Antibody- & Compelement- mediated demyelination. Ann Neurol. 1998, 43: 465. 55. Berger T, Rubner P, Schautzer F, et al. Antimyelin antibodies as a predictor of clinically definite multiple sclerosis after a first demyelinating event. N Eng J Med. 2003, 349: 139. 56. Jacobs L, Goodkin DE, Rudick RA, Hrendon R. Advances in specific therapy for multiple sclerosis. Curr opin Neurol. 1994, 7: 250. 57. Noseworthy JH, Lucchinetti C, Rodriguez M, Weinshenker BG. Multiple sclerosis. N Eng J Med. 2000, 343: 938. 58. Goodin DS, Frohman EM, Germany GP Jr, et al. Disease modifying therapies in multipe sclerosis. Report of the therapeutics & technology assesment subcommittee of the American Academy of Neurology & the MS Council for clinical practice
  • 150. Guidlines. Neurology. 2002, 58: 169. 59. Myers LW. Immunologic therapy for secondary & primary progressive multiple sclerosis. Curr Neurol Neurosci Rep. 2001, 1: 286. 60. Achiron A, Gabbay U, Gilad R, et al. IVIG treatment in multiple sclerosis. effect on relapses. Neurology. 1998, 50: 398. 61. Wiener HL, Dawson DM. Plasmapheresis in multiple sclerosis: Preliminary study. Neurology. 1980, 30: 1029. 62. Khatri Bo, MCQuillen MP, Hoffman RG, et al. Plasma exchange in chronic progressive multiple sclerosis: A long term study. Neurology. 1991, 41: 409. 63. Hauser SL, Dawson DM, Lehrich JR, et al. Intensive Immunosuppression in progressive MS: A randomized three-arm study of high dose Intravenous cyclophosphamide, plasma exchange & ACTH. N Eng J Med. 1983, 308: 173. 64. Tindall RSA, Walker JE, Ehle AL, et al. Plasmapheresis in MS: prospective trial of phresis & Immunosuppression versus Immunosuppression alone. Neurology. 1982, 32: 739. 65. Wiener HL. An assessment of plasma exchange in progressive multiple sclerosis. Neurology. 1985, 35: 320. 66. Goodin DS. The use of Immunosuppressive agents in the treatment of MS: A critical review. Neurology. 1991, 41: 980. 67. Wiener HL, Dau P, Khatri BO, et al. Double-blind study true versus sham plasma exchange in patients bieng treated with immunosuppression for acute attacks of MS. Neurology. 1989, 39: 1143. 68. Canadian cooperative MS study group.Canadian cooperative trial of cyclophosphamide & plasma exchange in progressive multiple sclerosis. Lancet. 1991, 337: 441. 69. Vamvakas EC, Pineda AA, Weinshenker BG. Meta-analysis of clinical studies
  • 151. TPE of the efficacy of plasma exchange in the treatment of chronic progressive multiple sclerosis. J. clin. Apheresis. 1995, 10: 163. 70. Archelos JJ, Storch MK, Hartung H-P. Neurological progress: The role of B cells & autoantibodies in MS. Ann Neurol. 2000, 47: 694. 71. Cross AH. MS: The return of the B cell. Neurology. 2000, 54: 1214. 72. Weinshenker BG, O'Brien PC, Petterson TM, et al. A randomized trial of plasma exchange in acute central nervous system inflammatory demyelinating disease. Ann Neurol. 1999, 46: 878. 73. Bosch EP, Smith BE. Peripheral neuropathies associated with monoclonal proteins. Med Clin North Am. 1993, 77: 125. 74. Mendell JR. Chronic inflammatory demyelinating polyradiculopathy. Annu Rev Med. 1993, 44: 211. 75. Dyck PJ, Low PA, Windebank AJ, et al. Plasma exchange in polyneuropathy associated with monoclonal gammopathy of undetermind significance. N Eng J Med. 1991, 325: 1482. 76. Weinstein R. Therapeutic apherersis in neurological disorders. J. clin. Apheresis. 2000, 15: 28. 77. Rodgers SW, Anderews PI, Gahring LC, et al. Autoantibodies to Glutamate receptor GluR3 in Rasmussen's encephalitis. Science. 1994, 265: 648. 78. Andrews PI, Dichter MA, Berkovik SF, et al. Plasmapheresis in Rasmussen's encephalitis. Neurology. 1996, 46: 242-6. 79. Swedo SE. Sydenham's chorea. A model for childhood autoimmune neuropsychiatric disorders. JAMA. 1994, 272: 1788. 80. Swedo SE. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry. 1998, 155: 264.
  • 152. 81. Husby G, Vande Rijin I, Zabriskie JB, et al. Antibodies reacting with cytoplasm of subthalamic & caudate nuclei neurons in Chorea & acute rheumatic fever. J Exp Med. 1976, 144: 1094. 82. Zabriskie JB. Rheumatic fever: A model for the pathological cosequences of microbial-host mimicry. Clin Exp Rheumatol. 1984, 4: 65. 83. Perlmutter SJ, Leitman SF, Garvey MA, et al. Therapeutic plasma exchange & IVIG for obsessive-compulsive disorders & tic disorders in childhood. Lancet. 1999, 354: 1153. 84. Nicolson R, Swedo SE, Bedwell J, et al. An open trial of plasma exchange in childhood-onset obsessive-compulsive disorders without post streptococcal exacerbation. J Am Acad Child Adolesc Psychiatry. 2000, 39: 1313. 85. Amorosi EL, Ultmann JE. Thrombotic thrombocytopenic purpura: report of 16 cases & review of the literature. Medicine. 1966, 45: 139. 86. Torok TJ, Holman Rc, Chorba TL. Increasing mortality from Thrombotic Thromnocytopenic purpura in the us. - analysis of national mortality data, 1968- 1991. Am J Hematol. 1995, 50: 84. 87. Cohen JA, Brecher ME, Bandarenko N. Cellular source of serum lactate dehydrogenase elevation in patients with TTP. J. clin. Apheresis. 1998, 13: 16. 88. George JN. How do I treat patients with thrombotic thrombocytopenic purpra- hemolytic uremic syndrome. Blood. 2000, 96: 1223. 89. Remmuzi G, Ruggenehti P. The hemolytic uremic syndrome. Kidney int. 1995, Jul;48: 2. 90. George JN, Vesely SK, Trell DR. The oklahama TTP-HUS registery: a community perspective of patients with clinically diagnosed TTP-HUS,. Semin Hematol. 2004, 41: 60. 91. Moake JL. Thrombotic microangiopethies. N Eng J Med. 2002, 347: 589.
  • 153. TPE 92. Furlan M, Robles R, Solenthaler M, et al. Deficient activity of vWF-cp in chronic relapsing thrombotic thrombocytopenic purpura. Blood. 1997, 89: 3097. 93. Furlan M, Robles R, Solenthaler M, et al. Aquired deficiency of vWF-cp in a patient with thrombotic thrombocytopenic purpura. Blood. 1998, 91: 2839. 94. Rice L, Tsai HM, Chow TW, Moake JL. Increased vonwillberand factor(vWF)- platelet binding & decreased vWF-metaloproteinase in ticlopidine-induced thrombotic thrombocytopenic purpura(TTP). Blood. 1998, 92(suppl 2): 706a. 95. Tsai HM, Lian EC. Antibodies to vWF-CP in acute TTP. N Eng J Med. 1998, 339: 1585. 96. Vanderplas RM, Schiphorst ME, Huizinga EG, et al. Von Willberand factor proteolysis is deficient in classic, but not in bone marrow transplantation associated thrombotic thrombocytopenic purpura. Blood. 1999, 93: 3798. 97. George JN, Gilsher RO, Smith JW, et al. TTP-HUS: diagnosis & management. J. clin. Apheresis. 1998, 13: 120. 98. Ruggeneti P, Noris M, Remuzzi G. Thrombotic microangiopathy, hemolytic uremic syndrome, & TTP. Kidney int. 2001, 60: 831. 99. George JN, Lix MC, Minn JR, et al. TTP-HUS following allogenic HPC transplantation: a diagnostic dilemma. Transfusion. 2004, 44: 294. 100. Sarode R, MacFarland JG, Flomenburg N, et al. Therapeutic plasma exchange dose not appear to be effective in the management of thrombotic thrombocytopenic purpura / hemolytic uremic syndrome following bone marrow transplantation. Bone Marrow Transplant. 1995, 16: 271. 101. Bell WR, Braine HG, Ness PM, et al. Improved survival in TTP-HUS. Clinical experience in 108 patients. N Eng J Med. 1991, 325: 398. 102. Dawson RB, Brown JA, Mahalati K, et al. Durable remissions following prolonged plasma exchange in TTP. J. clin. Apheresis. 1994, 9: 112.
  • 154. 103. Bandarenko N, Brecher ME. united states thrombotic thrombocytopenic purpura apheresis study group ( us TTP ASG ): Multicenter survey & retrospective analysis of current efficacy of therapeutic plasma exchange. J. clin. Apheresis. 1998, 13: 133. 104. Rock G, Shumak KH, Sutton DM, et al. Cryosupernatant as replacement fluid for plasma exchange in thrombotic thrombocytopenic purpura. members of the Canadian Apheresis Group. Br J Haematol. 1996, 94: 383. 105. Pereira A, Mazzara R, Monteagudo J, et al. TTP-HUS: A multivariate analysis factors predicting the response to plasma exchange. Ann Hematol. 1995, 70: 319. 106. Rock GA, Shumak KH, Buskard NA, et al. Comparison of plasma exchange with plasma infusion in the treatment of TTP. Canadian Apherersis Group. N Eng J Med. 1991, 325: 393. 107. Black all DP, Uhl L, Spitalnik SL. Cryoprecipitate-reduced plasma; rationale for use & efficacy in the treatment of TTP. Transfusion. 2001, 41: 840. 108. Zeigler ZR, Shadduck RR, Gryn JF, et al. The north American TTP Group. Cryo-precipitate poor plasma does not improve early response in primary adult TTP. J. clin. Apheresis. 2001, 16: 19. 109. Amorosi EL, Karpatkin S. Antiplatelet treatment of TTP. Ann Intern Med. 1977, 86: 102. 110. Gutterman LA, Stevenson TD. Treatment of TTP with Vincristine. JAMA. 1982, 247: 1433. 111. Crowther MA, Heddle N, Hayward CP, et al. Splenectomy done during hematologic remission to prevent relapse in patients with TTP. Ann Intern Med. 1996, 125: 294. 112. Hand JP, Lawlor ER, Young CK, et al. Successful use of Cyclosporin A in the treatment of refractory TTP. Br J Haematol. 1998, 100: 597.
  • 155. TPE 113. Centurioni R, Bobbio-Pallavicini E, Porta C, et al. Treatment of TTP with high-dose immunoglobulins. Result in 17 patients. Italian cooperative group for TTP. Haematologica. 1995, 80: 325. 114. Apter AJ, Kaplan AA. An approach to immunologic reactions associated with plasma exchange. J Allergy Clin Immunol. 1992, 90: 119. 115. O'Connor NT, Bruce JP, Hill LF. Vincristine therapy for TTP. Am J Hematol. 1992, 39: 234. 116. Bohm M, Betz C, Miesbach W, et al. The course of ADAMTS13 activity & inhibator liter in the treatment of TTP with plasma exchange & Vincristine. haematol. 2005, 129: 644. 117. Allan DS, Kovaks MJ, Clark WF. Frequently relapsing TTP treated with cytotoxic immunosuppressive. Haematologica. 2001, 86: 844. 118. Chintagumpala MM, Hurwitz RL, Moake JL, et al. Chronic relapsing TTP in infants with large vWF multimers during remissions. J Pediatr. 1992, 120: 49. 119. Mcleod Bc. Therapeutic apheresis: A physicians Handbook. 1st ed. Bethesda. AABB press, 2005:55-113. 120. Melnyk AMS, Solez K, Kjellstrand CM. Adult hemolytic-uremic syndrome. Arch Intern Med. 1995, 155: 2077 121. Loirat C, Baudouin V, Sonsino E, et al. HUS in the child. Adv Nephrol. 1993, 22: 141. 122. Furlan M, Robles R, Galbursera M, et al. vWF-cleaving protease in TTP & the HUS. N Eng J Med. 1998, 339: 1578. 123. Raugier N, Kazatachkine MD, Rougier J-P, et al. Human complement factor H deficiency associated with HUS. J AM Soc Nephrol. 1998, 9: 2318. 124. Warwicker P, Donne RL, Gaalship JA, et al. Familial relapsing hemolytic uremic syndrome & complement factor H deficiency. Nephrol Dial Transplant.
  • 156. 1999, 14: 1229. 125. McLeod BC. Therapeutic plasma exchange. In Hillyer CD, Silberstein L, Ness PM, Anderson KC, Roushk S (eds). Blood banking & transfusion medicine. Basic principles & practice. 1st ed. Churchil Livingstone, 2003:519-543. 126. Skoog WA, Adams WS. Plasmapheresis in a case of Waldenstrom's macroglobulinemia. Clin Res. 1959, 7: 96. 127. Schwab PJ, Fahey JL. Treatment of Waldenstrom's macroglobulinemia by plasmapheresis. N Eng J Med. 1960, 263: 574. 128. Foerster J. Plasma cell dyscrasias: General consideration. In lee GR, Bithell TC, Foerster J(eds): Wintrobe's clinical hematology. 9th ed.Philadelhpia, Lea & Febiger, 1993:2202-2218. 129. Mc Grath MA, Penny R. Blood hyperviscosity & clinical manifestations. J. clin. Invest. 1976, 58: 1155. 130. Bloch KJ, Maki DG. Hyperviscosity syndrome associated with immunoglobulin abnormalities. Semin Hematol. 1973, 10: 113. 131. Drew MJ. Therapeutic plasma exchange in Hematologic diseases & Dysproteinemia. In Mcleod Bc, Price TH, Weinstein R, eds. Apheresis: Principles & Practice. 2nd ed.AABB press, Bethesda., 2003:345-373. 132. Bear RA, Cole EH, Lang A, et al. Treatment of acute renal failure due to myeloma kidney. Can Med Assoc J. 1980, 123: 750. 133. Johnson WJ, Kyle RA, Dahlberg PJ. Dialysis in the treatment of multiple myeloma. Myoclinic proc. 1980, 55: 65. 134. Solling K, Solling J. Clearance of Bence-Jones proteins during peritoneal dialysis or plasmapheresis in myelomatosis associated with renal failure. Contrib Nephrol. 1988, 68: 259. 135. Otak AT. Plasma exchange vs peritoneal dialysis for removing Bence-Jones
  • 157. TPE protein. Br Med J. 1978, 1397. 136. Johnson WJ, Kyle RA, Pineda AA, et al. Treatment of renal failure associated with multiple myeloma. Plasmapheresis, hemodialysis,& chemotherapy. Arch Intern Med. 1990, 150: 863. 137. Zucchelli P, Passquali S, Cagnoli L, et al. Plasma exchange therapy in acute renal failure due to light chain myeloma. Trans Am Soc Artif Intern Organs. 1984, 30: 36. 138. Muller-Eckhardt C. Post transfusion pupura. Br J Haematol. 1986, 64: 419. 139. Newman PJ, MC Farland JG, Aster RH. Alloimmune Thrombocytopenias. In: Loscalzo J, Schafer A, eds. Thrombosis & Hemorrhage. 3rd ed.Lippincott Williams & Wilkins, 2003:441-456. 140. Weisberg LJ, Linker CA. Prednisone therapy of post transfusion purpura. Ann Intern Med. 1984, 100: 76. 141. Becker T, Panzer S, Maas , et al. High dose intravenous immunoglobulin for post transfusion purpura. Br J Haematol. 1985, 61: 149. 142. Roy V, Verfaille CM. Refractory thrombocytopenia due to anti-PLA1 antibodies following autologous peripheral blood stem cell transplantation. Bone Marrow Transplant. 1996, 17: 115. 143. Berney SI, Metcalfe P, Wathen NC, et al. Post transfusion purpura responding to high dose Intravenous IgG. Br J Haematol. 1985, 61: 627. 144. Mcleod Bc, Strauss RG, Ciavarella D, et al. Managment of Hematological disorders & cancer. J. clin. Apheresis. 1993, 8: 221. 145. Green D. Factor VIII & other coagulation factor inhibators. In Loscalzo J, Schaufer A: Thrombosis & Hemorrhage. 3rd ed.Lippincott Williams & Wilkins, 2003:599-610. 146. Ludlam CA, Morrison AE, Kessler C. Treatment of aquired hemophilia. Semin
  • 158. Hematol. 1994, 31(Suppl 4): 16. 147. Ghosh K, Shetty S, Pathare A, Monhanty D. Epsillon-amino caproic acid(EACA) inhibits the activity of factor VIII inhibators in patients with severe hemophilia. Acta Heamatologica. 2000, 103: 67. 148. Lusher J, Ingerselv S, Roberts H, et al. Clinical experience with recombinant factor VIIIa. Blood coagul Fibrinolysis. 1998, 9: 119. 149. Lusher JM. Managment of patients with factor VIII inhibators. Transfus Med Rev. 1987, 1: 123. 150. Pfleiger G, Boda Z, H'arsfalvi J, et al. Cyclosporine treatment of a woman with aquired hemophilia due to factor VIII:C inhibator. Postgard Med J. 1989, 65: 400. 151. Schwartz RS, Gabriel DA, Aledort LM, et al. A prospective study of treatment of aquired (autoimmune) factor VIII inhibators with high dose intravenous gammaglobulin. Blood. 1995, 86: 797. 152. Ewing NP, Sanders NL, Dietrich SL, et al. Induction of immune tolerance to factor VIII in hemophiliacs with inhibators. JAMA. 1988, 259: 65. 153. Gruppora RA, Valdez LP, Stout RP. Induction of immune tolerance in patients with hemophilia A & inhibators. Am J Pediatr Hematol Oncol. 1992, 4: 82. 154. Nilsson IM, Berntorp E, Zettervollo O. Induction of immune tolerance in patients with hemophilia & antibodies to factor VIII by combined treatment with IVIG, Cyclophosphamide,& factor VIII. N Eng J Med. 1988, 318: 947. 155. Smith OP, Hann IM. rVIIIa therapy to secure hemostasis during central line insertion in children with high-responding FVIII inhibitors. Br J Haematol. 1996, 92: 1002. 156. Nakamura Y, Yoshid aK, Itoh S, et al. Immunoadsorption plasmapheresis as a treatment for pregnancy complicated by SLE with positive antiphospholipid antibodies. Am J Reprod Immunology. 1999, 41: 307.
  • 159. TPE 157. Asherson RA, Cevara R, Piette JC, et al. Catastrophic antiphospholipid syndrome. Clinical & labratory features of 50 features. Medicine. 1998, 77: 195. 158. Szczepiorkowski ZM. TPE in renal, rheumatic,& miscellaneous disorders. In Mcleod BC, Price TH, Weinstein R, eds: Apheresis: Principles & practice. 2nd ed.Bethesda,MD: AABB press. 2003:375-409. 159. Watson WJ, Katz VL, Bowes WA. Plasmapheresis during pregnancy. Obstet Gynecol. 1990, 76: 451. 160. Gale RP, Feig S, Ho W, et al. ABO blood group system & bone marrow transplantation. Blood. 1977, 50: 185. 161. Bensinger WI, Baker DA, Buckner DD, et al. Immunoadsorption for removal of A & B blood group antibodies. N Eng J Med. 1981, 301: 160. 162.Braine HG, Sensenbrenner LL, Wright SK, et al. Bone marrow transplantation with major incompatibility using erythrocyte depletion of marrow prior to infection. Blood. 1982, 60: 420 163.Gmur JP, Burger J, Schaffner A, et al. Pure red cell aplasia of duration complicating major ABO incompatible bone marrow transplantation. Blood. 1990, 75: 290. 164. Fischel RJ, Ascher NL, Payne WD, et al. Pediatric liver transplantation across ABO blood group barriers. Transplant Proc. 1989, 21: 2221. 165. Mor E, Skerrett D, Manzarbeitia C, et al. Successful use of an enhanced immunosuppressive protocol with plasmapheresis for ABO-incompatible mismatched grafts in liver transplant recipient. Transplantation. 1995, 59: 986. 166. Ramsey G. Red cell antibodies arising from solid organ transplants. Transfusion. 1991, 31: 76. 167. Ludgren G, Asba H, Bergstrom J, et al. Fulminating anti-A autoimmune hemolysis with anuria in a renal transplant recipient. Clin Nephrol. 1981, 16: 211.
  • 160. 168. Kickler TS. The challenge of platelet alloimmunization: Management & prevention. Transfusion. 1990, 30: 8. 169. Bensinger WI, Buckner CD, Clift RA, et al. Plasma exchange for platelet alloimmunization. Transplantation. 1986, 41: 602. 170. Christie DJ, Howe RB, Lennon SS, et al. Treatment of refractoriness to platelet transfusion by protein A column therapy. Transfusion. 1993, 33: 234. 171. Lee EJ, Norris D, Schiffer CA. IVIG for patients alloimmunized to random donor platelet transfusions. Transfusion. 1987, 27: 245. 172. Rickler T, Braine HG, Pianatadosi S, et al. A randomized, placebo-controlled trial of IVIG in alloimmunized thrombocytopenic patients. Blood. 1987, 70: 313. 173. George JN, EL-Harake MA, Aster RH. Thrombocytopenia due to enhanced platelet destruction by immunologic mechanisms. In Beutler E, Lichtman MA, Coller BS, et al(eds): Williams Hematology. 5th ed.MC Graw-Hill, 1995:1315. 174. Fujimara K, Takafuta T, Kuriya S, et al. Recombinant human interferon alpha- 2b (rh IFN alpha-2b) therapy steroid resistant idiopathic thrombocytopenic purpura. Am J Hematol. 1996, 51: 37. 175. Branda RF, Tate DY, Mc Cullough JJ, et al. Plasma exchange in the treatment of fulminant idiopathic (autoimmune) thrombocytopenic purpura. Lancet. 1978, i: 688-91. 176. Marder VJ, Nusbacher J, Anderson FW. One-year follow up of plasma exchange therapy in 14 patients with ITP. Transfusion. 1981, 21: 291. 177. Silverman GJ, Goodyear CS, Siegel DL. On the mechanism of staphylococcal protein A immunomodulation. Transfusion. 2005, 45: 274. 178. Synder HW Jr, Cochran SK, Balint JP, et al. Experience with protein-A immunoadsorption in treatment resistant immune thrombocytopenic patients. Blood. 1992, 79: 2237.
  • 161. TPE 179. George JN, Woolf SH, Raskob GE, et al. Idiopathic thrombocytopenic purpura: A practice guidline developed by explicit methods for the American Society of Hematology. Blood. 1996, 88: 3. 180. Packman CH, Leddy JP. Aquired hemolytic anemia due to warm reacting autoantibodies. In Beutler E, Lichman MA, Coller BS, et al(eds): Williams Hematology. 5th ed.MC Graw Hill, 1995:677. 181. Packman CH, Leddy JP. Cryopathic hemolytic syndrome.In Beutler E, Lichman MA, Coller BS, et al(eds): Williams Hematology. 5th ed.MC Graw Hill, 1995:685. 182. Silberstein LE, Berkman EM. Plasma exchange in autoimmune hemolytic anemia (AIHA). J. clin. Apheresis. 1983, 1: 238. 183. Geurs F, Ritter K, Mast A, et al. Successful plasmapheresis in corticosteroid- resistant hemolysis in infectious mononucleosis, role of autoantibodies against triosephosphate isomerase. Acta Heamatol. 1992, 80: 142. 184. Zoppi M, Oppliger R, Althaus U. Reduction of plasma cold agglutinin titers by means of plasmaphersis to prepare a patient for coronary bypass surgery. Infectiuos ther Transfusion Medicine. 1993, 20: 19. 185. Sato S, Fuchinoue S, Abe M, et al. Successful cytokine treatment of aplastic anemia following Living-related orthotopic Liver transplantation fornon A, non B, non C hepatitis. Clin Transplant. 1999, 13(1part1): 68. 186. Stachel D, Schmid I, Lang T, et al. Double bone marrow transplantation for severe aplastic anemia after orthotopic liver transplantation: Implication for clinical managemant and immune tolerance. Transplant Int. 2002, 15: 39. 187. Young NS, Barrett AJ. The treatment of sever aquired aplastic anemia. Blood. 1995, 85: 3367. 188. Maciejewski JP, Hibbs JR, Anderson S, et al. Bone marrow & peripheral blood
  • 162. lymphocyte type in patients with bone marrow failure. Exp Hematol. 1994, 22: 1102. 189. Shadduck RK. Aplastic anemia. In Beutler E, Lichtman MA, Coller BS, Kipps TJ (eds): Williams Hematology. 5th ed.MC Grew Hill, 1995:238. 190. Fitchen JJ, Cline MJ, Saxon A, et al. Serum inhibitors of hematopoiesis in a patient with aplastic anemia & systemic lupus erythmatosus. Am J Medicine. 1979, 6: 537. 191. Brouet JC, Clauvel JP, Danon F, et al. Biologic & clinical significance of cryoglobulins: a report of 86 cases. Am J Medicine. 1974, 57: 775. 192. Lunel F, Musset L. Hepatitis C infection & cryoglobulinemia. Trends Exp Clin Med. 1998; 8: 95. 193. Bloch KJ, Maki DG. Cryoglobulinemia & hepatitis C. N Eng J Med. 1992, 327: 1521. 194. Foerster J. Cryoglobulins & cryoglobulinemia. In lee GR, Bithell TC, Foerster J(eds): Wintrobe's clinical hematology. 9th ed.Philadelphia, Lea & Febiger, 1993:2284. 195. Gorevic PD, Kassab HJ, Levo Y, et al. Mixed cryoglobulinemia; Clinical aspects & long term follow up of 40 patients. Am J Medicine. 1980, 69: 287. 196. D'Amico G, Golastani G, Ferrario F. Renal involvement in essential mixed cryoglobulinemia. Kidney Int. 1989, 35: 1004. 197. Hillyer CD, Berkman EM. Plasma exchange in dysproteinemias. In: Rossi EC, Simon TL, Moss GS, et al(eds): Principles of transfusion medicine. 2nd ed.Williams & Wilkins, 1996:569-575. 198. McLeod BC, Sassetti RJ. Plasmapheresis with return of cryoglobulin depleted autologous plasma (cryoglobulinpheresis) in cryoglobulinemia. Blood. 1980, 55: 866.
  • 163. TPE 199. Berkman EM, Orlin JB. Use of plasmapheresis & partial plasma exchange in the management of patients with cryoglobulinemia. Transfusion. 1980, 20: 171. 200. Bommbardieri S, Maggiore Q, L Abbate A, et al. Plasma exchange in essential mixed cryoglobulinemia. Plasma ther Transfus Technol. 1981, 2: 101. 201. Mc Gowvern TW, Enzenauer RJ, Fitzpatrick JE. Treatment of recalcitrant leg ulcers in cryoglobulinemia type I & II with plasmapheresis. Arch Dermatol. 1996, 132: 498. 202. Evans TN, Nicholls AJ. Acute renal failure in essential mixed cryoglobulinemia; Percipitation & reversal by plasma exchange. Clin Nephrol. 1984, 21: 287. 203. Valbonesi M, Garelli S, Mntani F. Management of immune-mediated & paraproteinemic disease by membrane plasma seperation & cascade filtration. Vox Sanguinis. 1982, 43: 91. 204. Nephrology Forum; Lymphoma, cryoglobulinemia & renal disease. Kidney int. 1979, 16: 522. 205. Wiseman KC. New insights on Goodpasture's syndrome. ANNA J. 1993, 20: 17. 206. Kallari R, Gunwar S, Reeders ST, et al. Goodpasture syndrome localization of the epitope for the autoantibodies to the carboxy terminal region of the alpha 3(IV) chain of basement membrane collagen. J Biol Chem. 1991, 266: 24018. 207. O'Mera YM, Brady HR, Brenner BM. Glomerolupathies associated with multisystem disorders. In: Braunwald E, Fauci AS, Kasper DL, et al. Harrison's principles of internal medicine. 15th ed.New York. MC Graw-Hill, 2001:1590-8. 208. Kluth DC, Rees AJ. Antigumerular basement membrane disease. J Am Soc Nephrol. 1999, 10: 2446. 209. Pusey CD, Lockwood CM, Peters DK. Plasma exchange &
  • 164. immunosuppressive drugs in the treatment of glomerulonephritis due to antibodies to glomerular basement membrane. Int J Artif Organs. 1983, 6: 15. 210. Glassok RJ. Intensive plasma exchange in crescentric glomerulonephritis: help or no help? Am J Kidney Dis. 1992, 20: 270. 211. Levy JB, Turner AN, Rees AJ. long term outcome of antiglomerular basement membrane antibody disease with plasma exchange & immunosuppression. Ann Intern Med. 2001, 134: 1033. 212. Kaplan AA. The use of apheresis in immune renal disorders. Ther Apheresis Dial. 2003, 7: 165. 213. Bolton WK. Goodpasture's syndrome. Kidney int. 1996, 50: 1753. 214. Johnson JP, Moore J, Austin HA, et al. Therapy of anti-glomeruler basement membrane antibody disease: analysis on the prognostic significance of clinical, pathogenic & treatment features. Medicine. 1985, 64: 219. 215. Lewis EJ, Shwartz MN. Idiopathic crescentric glomerulonephritis. Semin Nephrol. 1982, 21: 193. 216. Jayne DRW, Marshal PD, Jones SJ, et al. Autoantibodies to GBM & neutrophil cytoplasm in rapidly progressive glomerulonephritis. Kidney int. 1990, 37: 965. 217. Glassock RJ, Cohen AH, Adler SG. Primary glomerular diseases. In Brener BM(ed): The kidney. Philadelphia, WB Saunders, 1996:1392. 218. Goronzy J, Weyland C. Rhuematoid artheritis. In Klipel J(ed): Primer on the Rheumatic disease. Atlanta, Arthritis foundation, 1997:155. 219. Paget S. Rheumatoid arthritis, treatment. In Klipel J(ed): Primer on the Rheumatic disease. Atlanta, Arthritis foundation, 1997:168. 220. Moreland LW. Inhibitors of tumor necrosis factor for rheumatoid arthritis. J Rheumatol. 1999, 26(suppl57): 7. 221. Levy J, Degani N. Correcting immune imbalance. The use of Prosorba column
  • 165. TPE treatment for immune disorders. Ther Apheresis Dial. 2003, 7: 197. 222. Matic G, Bosch T, Ramlow W. Background & indications for protein A-based extracorporeal immunoadsorption. Ther Apheresis. 2001, 5: 394-403. 223. Bacon PA. The spectrum of wegner's granulomatosis & disease relapse. N Eng J Med. 2005, 352: 330. 224. Cupps T. Vasculitis: epidemiology, pathology, & pathogenesis. In Klipell(ed): Primer on the Rheumatic disease. Atlanta, Arthritis foundation, 1997:289. 225. Hoffman G. Vasculitis: treatment. In Klipel J(ed): Primer on the Rheumatic disease. Atlanta, Arthritis foundation, 1997:301. 226. Pusey CD, Rees AJ, Evans DJ, et al. Plasma exchange in focal necrotizing glomerulonephritis without anti-GBM antibodies. Kidney int. 1991, 40: 757. 227. Guillevin L, Fain O, Lhote F, et al. Lack of superiority of steroids plus plasma exchange to steroids alone in the treatment of polyarteritis nodosa & churg-strauss syndrome. Arthritis Rheum. 1992, 35: 208. 228. Guillevin L, Cevallos R, Durand-Gasselin B. Treatment of glomerulonephritis in microscopic polyangitis & churg-strauss syndrome. Indication of plasma exchanges, metaanalysis of 2 randomized study. Ann Med Intern (Paris). 1997, 148: 198. 229. Klemmer PJ, Chalerm S, Kulrat W. Plasmapheresis therapy for diffuse alveolar hemorrage in patients with small vessel vasculitis. Am J Kidney Dis. 2003, 42: 1149. 230. Guillevin L, Pagnoux C. Indication of plasma exchange for systemic vasculitis. Ther Apheresis Dial. 2003, 7: 155 231. Winkel E, Disesa VJ, Costanzo MR. Advances in heart transplantation. Dis Mon. 1999, 45: 63. 232. Montgomery RA, Zachary AA, Racusen LC, et al. Plasmapheresis & IVIG
  • 166. provides effective rescue therapy for refractory humoral rejection & allows kidneys to be successfully transplanted in to crossmatch-positive recipients. Transplantation. 2000, 70: 887. 233. Kirlin JK, Baurge RC, MC Giffin DC. Recurrent or persistent allograft rejection: therapeutic options & recommendations. Transplant Proc. 1997, 29(suppl 8a): 40s. 234. Bonomini V, Vangelista A, Frasca GM, et al. Effects of plasmapheresis in renal transplant rejection: a controlled study. Trans Am Soc Artif Intern Organs. 1985, 31: 698. 235. Blake P, Sutton D, Cardella C. Plasma exchange in acute renal transplant rejection. Prog Clin Biol Res. 1990, 337: 249. 236. Loss GE Jr, Grewal HP, Siegel CT, et al. Reversal of delayed hyperacute renal allograft rejection with a tacrolimus-based therapeutic regimen. Transplant Proc. 1998, 30: 1249. 237. Aichberger C, Nussbaumer W, Rosmanith P, et al. Plasmapheresis for the treatment of acute vascular reaction in renal transplantation. Transplant Proc. 1997, 29: 169. 238. Abe M, Sannomiya A, Koike T, et al. Removal of anti-donor antibody by double filtration plasmapheresis to prevent chronic rejection in kidney transplantation. Transplant Proc. 1998, 30: 3108. 239. Costanzo-Nordin, Herox AL, Radvany R, et al. Role of humoral immunity in acute cardiac allograft rejection. J Heart Lung Transplant. 1993, 12: S 143. 240. Heroux AL, Costanzo -Nordin MR, Radvany R, et al. The enigma of acute allograft dysfunction without cellar rejection: role of humoral immunity. J Heart Lung Transplant. 1993, 12: S 91. 241. Hodge EE, Klingman LL, Koo AP, et al. Pretransplant removal of anti-HLA
  • 167. TPE antibodies by plasmapheresis & continued suppression on cyclosporin-based therapy after heart-kidney transplant. Transplant Proc. 1994, 26: 2750. 242. Hakim R, Milford E, Himmelfarb J, et al. Extracorporel removal of anti-HLA antibodies in transplant candidates. Am J Kidney Dis. 1990, 16: 423. 243. Miura S, Okazaki H, Sato T, et al. Beneficial effects of double-filtration plasmapheresis on living related donor renal transplantation in presensitized recipients. Transplant Proc. 1995, 27: 1040. 244. Miura S, Okazaki H, Sato T, et al. Successful renal transplantation in presensitized recipients with double-filtration plasmapheresis & 15- deoxyspergualin. Transplant Proc. 1997, 29: 350. 245. Ishikawa A, Itoh M, Ushlyama T, et al. Experience of ABO-incompatible living kidney transplantation after double filtration plasmapheresis. Clin Transplant. 1998, 12: 80. 246. Takahashi K, Yogisawa T, Sonda K, et al. ABO-incompatible kidney transplantation in a single center trial. Transplant Proc. 1993, 25: 271. 247. Mor E, Skerrett D, Manzarbeitia C, et al. Successful use of an enhanced immunosuppressive protocol with plasmapheresis for ABO-incompatible mismatched graft in liver transplantation recipient. Transplantation. 1995, 59: 986. 248. Atero ML, Sharma S, Savin VJ, et al. Plasmapheresis reduces proteinuria & serum capacity to injure glomeruli in patients with recurrent focal glomerulosclerosis. Am J Kidney Dis. 1994, 23: 574. 249. Savin VJ, Sharma R, Sharma M, et al. Circulating factor associated with increased glomerular permeability to albumin in recurrent recurrent focal segmental glomerulosclerosis. N Eng J Med. 1996, 334: 878. 250. Thiery J, Meiser B, Wenke K, et al. Heparin-induced extracorporeal low density lipoprotein plasmaphersis (HELP) & its use in heart transplant patients with
  • 168. severe hypercholestrolemia. Transplant Proc. 1995, 27: 1950. 251. Barr ML, MC Laghlin SN, Murphy MP, et al. Prophylactic photopheresis & effect on graft atherosclerosis in cardiac transplantation. Transplant Proc. 1995, 27: 1993. 252. Gordon B, Stein E, Jones P, et al. Indication for LDL apheresis. Am J Cardiol. 1994, 74: 1109. 253. Thompson GR, Miller JP, Breslow JL. Improved survival of patients with homozygous familial hypercholostrolemia treated with plasma exchange. Br Med J. 1985, 291: 1671. 254. Kamanabroo D, Ulrich K, Grobe H, et al. Plasma exchange in type II hypercholestrolemia. Prog Clin Biol Res. 1988, 255: 347. 255. Leren TP, Fagerhol MK, Leren P. Sixteen years of plasma exchange in a homozygote for familial hypercholestolemia. J Intern Med. 1993, 233: 195. 256. Biegel Y, Bar J, Cohen M, et al. Pregnancy outcome in familial homozygous hypercholestolemic females treated wtih long-term plasma exchange. Acta Obstet Gynecol Scand. 1998, 77: 603. 257. Mcleod Bc. Therapeutic apheresis: A physicians Handbook. 1st ed.Bethesda. AABB press., 2005:163-180. 258. Thompson GR, Maher VM, Matthews S, et al. Familial hypercholestolemia regression study: A randomized trial of LDL apheresis. Lancet. 1995, 345: 811. 259. Shulzeck P, Olbricht CJ, Koch KM. Long term experience with extracorporeal LDL cholestrol removal by dextran sulfate cellulose adsorption. Clin Investig. 1992, 70: 99. 260. Dickson N, Mortimer JG, Faced JM, et al. A child with Refsum's disease: successful treatment with diet & plasma exchange. Dev Med Child Neurol. 1989, 31: 81.
  • 169. TPE 261. Robertson EF, Paulos A, Sharp P, et al. Treatment of infantile phytanic acid storage disease: clinical, biochemical & ultrastructural findings in two children treated for 2 years. Eur J Pediatr. 1988, 147: 133. 262. Harari D, Gibberd FB, Dick JPR, et al. Plasma exchange in the treatment of Refsum's disease( heredopathia atactica polyneuritiformis). J Neurol Neurosurg Psychiatry. 1991, 54: 614. 263. Gibberd FB. Plasma exchange for Refsum's disease. Trans Sci. 1993, 14: 23. 264. Gutsche H-U, Siegmond JB, Hoppmann I. Lipapheresis: an immunoglobulin- sparing treatment for Refsum's disease. Acta Neurol Scand. 1996, 94: 190. 265. Trujillo MH, Guerrero J, Fragachan C. Pharmacologic antidotes in critical care medicine: a practical guide for drug administration. Crit Care Med. 1998, 26: 377. 266. Jones JS, Daugherty J. Current status of plasmapheresis in toxicology. Ann Emerg Med. 1986, 15: 474. 267. Lee WM. Acute liver failure. Am J Medicine. 1994, 96: 3S. 268. Lee WM. Acute liver falilure. N Eng J Med. 1993, 329: 1862. 269. Caraceni P, Van Thiel DH. Acute liver failure. Lancet. 1995, 345: 163.