Effect of combined treatment with immunoadsorption and membrane filtration on plasma coagulation--Results of a randomized controlled crossover study.
The combined use of immunoadsorption (IA) and membrane filtration (MF) may markedly enhance removal of IgM and complement component C1q, supporting its use as an element of recipient desensitization in antibody-incompatible transplantation. However, coagulation factor removal may contribute to altered hemostasis, posing a risk of bleeding in the perioperative setting. This secondary endpoint analysis of standard coagulation assays and rotational thromboelastometry (ROTEM®) was performed in the context of a randomized controlled crossover study designed to assess the effect of combined IA (GAM-146-peptide) and MF on levels of ABO antigen-specific IgM. Fourteen patients with autoimmune disorders were randomized to a single treatment with IA+MF followed by IA alone, or vice versa. MF was found to markedly enhance fibrinogen depletion (57% vs. 28% median decrease after IA alone, P < 0.001), whereby four patients showed post-treatment fibrinogen concentrations below 100 mg dL(-1). In support of a critical contribution of fibrinogen depletion to impaired coagulation, extrinsically activated ROTEM(®) analysis revealed a marked reduction in fibrinogen-dependent clot formation upon IA+MF (59% median decrease in FIBTEM mean clot firmness (MCF) as compared to 24% after IA alone, P < 0.001). Moreover, the addition of MF led to a substantial prolongation of activated partial thromboplastin time, possibly due to depletion of macromolecular coagulation factors contributing to intrinsically activated coagulation. Our study demonstrates substantial effects of combined IA+MF on clot formation, which may be mainly attributable to fibrinogen depletion. We suggest that the use of combined apheresis in the setting of transplant surgery may necessitate a careful monitoring of coagulation.
Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
Peter
P
Biesenbach
Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
Farsad
F
Eskandary
Division of Hematology and Hemostaseology, Department of Medicine I, Medical University Vienna, Vienna, Austria.
Cihan
C
Ay
Department of Anaesthesia, General Intensive Care and Pain Control, Medical University Vienna, Vienna, Austria.
Marion
M
Wiegele
Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
Kurt
K
Derfler
Department of Anaesthesia, General Intensive Care and Pain Control, Medical University Vienna, Vienna, Austria.
Eva
E
Schaden
Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria.
Helmuth
H
Haslacher
Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
Rainer
R
Oberbauer
Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
Georg A
GA
Böhmig
D000017:ABO Blood-Group System / Q000097:blood; D000328:Adult; D001327:Autoimmune Diseases / Q000097:blood / Q000276:immunology / Q000628:therapy; D001777:Blood Coagulation; D001780:Blood Coagulation Tests; D001781:Blood Component Removal / Q000379:methods; D015922:Complement C1q / Q000302:isolation & purification / Q000378:metabolism; D018592:Cross-Over Studies; D005260:Female; D005340:Fibrinogen / Q000302:isolation & purification / Q000378:metabolism; D005374:Filtration / Q000379:methods*; D006801:Humans; D007075:Immunoglobulin M / Q000097:blood / Q000302:isolation & purification; D007163:Immunosorbent Techniques / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D013916:Thrombelastography
D000017:ABO Blood-Group System; D007075:Immunoglobulin M; D015922:Complement C1q; D005340:Fibrinogen
coagulation; fibrinogen; immunoadsorption; membrane filtration; rotational thromboelastometry