title: Assessment of Hemostasis after Plasma Exchange Using Rotational Thrombelastometry (ROTEM).
abstract: BACKGROUND
  Therapeutic plasma exchange (TPE)-based protocols immediately before cadaveric donor kidney transplantation have been extensively used in highly sensitized recipients. Plasma is generally preferred over human albumin as replacement fluid to avoid depletion of coagulation factors and perioperative bleeding. The aim of this study was to estimate bleeding risk after TPE replaced with albumin using rotational thromboelastography (ROTEM).
  
  
  METHODS
  Ten patients without overt coagulation abnormalities underwent TPE. Standard laboratory coagulation tests (thromboplastin time, activated partial thromboplastin time (aPTT), international normalized ratio (INR), thrombin clotting time, fibrinogen levels and antithrombin activity) were compared with thrombelastometry analysis (EXTEM and INTEM tests) before and after TPE.
  
  
  RESULTS
  TPE significantly reduced fibrinogen levels (482 ± 182 vs. 223 ± 122 mg/dL), antithrombin activity (103 ± 11 vs. 54 ± 11 %), and prolonged aPTT (28 ± 3 vs. 45 ± 8 s), thromboplastin time (108 ± 11 vs. 68 ± 11 %), INR (0.95 ± 0.06 vs. 1.25 ± 0.16), and thrombin clotting time (18 ± 2 vs. 20 ± 3 s). INTEM and EXTEM analyses revealed significantly prolonged clot-formation time and reduced maximum clot firmness.
  
  
  CONCLUSIONS
  TPE replaced with albumin induces significant changes in global hemostasis parameters thus potentially increasing bleeding risk. Therefore, pretransplant TPE should be considered carefully in indicated patients before kidney transplantation. The role of the ROTEM point-of-care test to estimate the risk of bleeding in renal transplantation needs to be evaluated in further studies.
authors.affiliation: Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Albert-Schweitzer-Campus 1, Münster, 48149, Germany.
authors.forename: Gerold
authors.initials: G
authors.lastname: Thölking
authors.affiliation: Department of Medicine A, Division of Hematology and Oncology, University Hospital of Münster, Albert-Schweitzer-Campus 1, Münster, 48149, Germany.
authors.forename: Rolf
authors.initials: R
authors.lastname: Mesters
authors.affiliation: Department of Neurology, University Hospital of Münster, Albert-Schweitzer-Campus 1, Münster, 48149, Germany.
authors.forename: Ralf
authors.initials: R
authors.lastname: Dittrich
authors.affiliation: Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Albert-Schweitzer-Campus 1, Münster, 48149, Germany.
authors.forename: Hermann
authors.initials: H
authors.lastname: Pavenstädt
authors.affiliation: Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Albert-Schweitzer-Campus 1, Münster, 48149, Germany.
authors.forename: Philipp
authors.initials: P
authors.lastname: Kümpers
authors.affiliation: Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Albert-Schweitzer-Campus 1, Münster, 48149, Germany.
authors.forename: Stefan
authors.initials: S
authors.lastname: Reuter
mesh_terms: D000328:Adult; D000991:Antithrombins / Q000378:metabolism; D001777:Blood Coagulation; D001780:Blood Coagulation Tests / Q000379:methods; D015331:Cohort Studies; D005260:Female; D005340:Fibrinogen / Q000096:biosynthesis; D006470:Hemorrhage; D006487:Hemostasis; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D010314:Partial Thromboplastin Time / Q000379:methods; D010951:Plasma Exchange / Q000379:methods*; D019095:Point-of-Care Systems; D012306:Risk; D013916:Thrombelastography / Q000379:methods; D013917:Thrombin / Q000737:chemistry; D013918:Thrombin Time; D055815:Young Adult
chemical_list: D000991:Antithrombins; D005340:Fibrinogen; D013917:Thrombin