title: Automated red blood cell exchange for acute drug removal in a patient with sirolimus toxicity.
abstract: Sirolimus is an immunosuppressant used to prevent graft versus host disease in allogeneic hematopoietic stem cell transplant recipients. It has a large volume of distribution (12 ± 7.5 l/kg) and within the intravascular space ∼95% of it is bound to red blood cells. Because of potential toxic effects at high trough levels, therapeutic drug monitoring is recommended for sirolimus. We present a case of severe hepatic dysfunction due to Hepatitis B and sirolimus toxicity, in a 51-year-old male stem cell transplant recipient. An automated red cell exchange decreased his blood sirolimus level from 22.6 to 10.3 ng/ml (55% reduction) and improved his liver enzymes. Re-equilibration of sirolimus from other compartments to the blood necessitated a series of four red cell exchanges, after which the sirolimus level was 4.7 ng/ml. Although the patient ultimately succumbed to multiorgan failure, red cell exchange may be considered for acute removal of sirolimus in selected patients.
authors.affiliation: Transfusion Medicine and Apheresis Service, UMass Memorial Medical Center, Worcester, Massachusetts.|Department of Pathology, University of Massachusetts Medical School, Worcester, Massachusetts.
authors.forename: Pallavi
authors.initials: P
authors.lastname: Galera
authors.affiliation: Transfusion Medicine and Apheresis Service, UMass Memorial Medical Center, Worcester, Massachusetts.|University of Massachusetts Medical School, Worcester, Massachusetts.
authors.forename: Hannah C
authors.initials: HC
authors.lastname: Martin
authors.affiliation: Transfusion Medicine and Apheresis Service, UMass Memorial Medical Center, Worcester, Massachusetts.
authors.forename: Linda
authors.initials: L
authors.lastname: Welch
authors.affiliation: Transfusion Medicine and Apheresis Service, UMass Memorial Medical Center, Worcester, Massachusetts.
authors.forename: Paula
authors.initials: P
authors.lastname: Sulmasy
authors.affiliation: University of Massachusetts Medical School, Worcester, Massachusetts.|Division of Hematology/Oncology, UMass Memorial Medical Center, Worcester, Massachusetts.|Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.
authors.forename: Jan
authors.initials: J
authors.lastname: Cerny
authors.affiliation: Transfusion Medicine and Apheresis Service, UMass Memorial Medical Center, Worcester, Massachusetts.
authors.forename: Mindy
authors.initials: M
authors.lastname: Greene
authors.affiliation: Transfusion Medicine and Apheresis Service, UMass Memorial Medical Center, Worcester, Massachusetts.
authors.forename: Michelle
authors.initials: M
authors.lastname: Vauthrin
authors.affiliation: Transfusion Medicine and Apheresis Service, UMass Memorial Medical Center, Worcester, Massachusetts.|Department of Pathology, University of Massachusetts Medical School, Worcester, Massachusetts.|University of Massachusetts Medical School, Worcester, Massachusetts.|Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.|Division of Transfusion Medicine, UMass Memorial Medical Center, Worcester, Massachusetts.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Bailey
authors.affiliation: Transfusion Medicine and Apheresis Service, UMass Memorial Medical Center, Worcester, Massachusetts.|Department of Pathology, University of Massachusetts Medical School, Worcester, Massachusetts.|University of Massachusetts Medical School, Worcester, Massachusetts.|Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.|Division of Transfusion Medicine, UMass Memorial Medical Center, Worcester, Massachusetts.
authors.forename: Robert
authors.initials: R
authors.lastname: Weinstein
mesh_terms: D001781:Blood Component Removal / Q000379:methods*; D016903:Drug Monitoring; D017707:Erythrocyte Transfusion / Q000379:methods*; D004912:Erythrocytes / Q000378:metabolism*; D017809:Fatal Outcome; D006086:Graft vs Host Disease / Q000517:prevention & control; D018380:Hematopoietic Stem Cell Transplantation / Q000009:adverse effects; D006801:Humans; D007166:Immunosuppressive Agents / Q000097:blood* / Q000302:isolation & purification / Q000633:toxicity*; D017093:Liver Failure / Q000139:chemically induced / Q000628:therapy; D008297:Male; D008875:Middle Aged; D020123:Sirolimus / Q000097:blood* / Q000302:isolation & purification / Q000633:toxicity*
chemical_list: D007166:Immunosuppressive Agents; D020123:Sirolimus
keywords: apheresis; drug overdose; immunosuppression; liver failure; stem cell transplant